Provider Demographics
NPI:1952492712
Name:MOUAZZEN, BASSAM (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:
Last Name:MOUAZZEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1939
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-1939
Mailing Address - Country:US
Mailing Address - Phone:626-852-9986
Mailing Address - Fax:626-963-2220
Practice Address - Street 1:415 W ROUTE 66
Practice Address - Street 2:SUITE 101
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4335
Practice Address - Country:US
Practice Address - Phone:626-852-9986
Practice Address - Fax:626-963-2220
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43066174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHC140778OtherFLOUROSCOPY
CA1625227Medicaid
CA1625227Medicaid
CA1625227Medicaid
CAAM8852039OtherDEA