Provider Demographics
NPI:1740451079
Name:ISMAEL, OUSAMA (MD)
Entity type:Individual
Prefix:DR
First Name:OUSAMA
Middle Name:
Last Name:ISMAEL
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 1:12223 HIGHLAND AVE
Mailing Address - Street 2:SUITE 106, BOX 607
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739
Mailing Address - Country:US
Mailing Address - Phone:909-996-0333
Mailing Address - Fax:
Practice Address - Street 1:1869 N WATERMAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4830
Practice Address - Country:US
Practice Address - Phone:909-881-0030
Practice Address - Fax:909-881-0040
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100770207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicare UPIN