Provider Demographics
NPI:1275679375
Name:SHAMONKI, ISSA MOUSA SR (MD)
Entity Type:Individual
Prefix:DR
First Name:ISSA
Middle Name:MOUSA
Last Name:SHAMONKI
Suffix:SR
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 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 770 W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-829-4781
Mailing Address - Fax:310-828-3874
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 770 W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-829-4781
Practice Address - Fax:310-828-3874
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA030208207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4456616Medicaid
CAW6003Medicare PIN
CA4456616Medicaid