Provider Demographics
NPI:1942575022
Name:BOSHRA, HEBA A (MD)
Entity Type:Individual
Prefix:
First Name:HEBA
Middle Name:A
Last Name:BOSHRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEBA
Other - Middle Name:A
Other - Last Name:ROUMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7331 SHELBY PL
Mailing Address - Street 2:UNITE 90
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-5903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8110 MANGO AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3603
Practice Address - Country:US
Practice Address - Phone:909-822-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGW478X-ZMedicare PIN