Provider Demographics
NPI:1003656802
Name:MUBARKEH, BASIL
Entity type:Individual
Prefix:
First Name:BASIL
Middle Name:
Last Name:MUBARKEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18201 SHANNON RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-8135
Mailing Address - Country:US
Mailing Address - Phone:661-839-3915
Mailing Address - Fax:
Practice Address - Street 1:45104 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2310
Practice Address - Country:US
Practice Address - Phone:661-941-9543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35675152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist