Provider Demographics
NPI:1831148501
Name:ABAZA, MOUTASEM (MD)
Entity type:Individual
Prefix:
First Name:MOUTASEM
Middle Name:
Last Name:ABAZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:ABAZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1111 GRAND AVE STE K
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4172
Mailing Address - Country:US
Mailing Address - Phone:098-604-2549
Mailing Address - Fax:
Practice Address - Street 1:1111 GRAND AVE STE K
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4172
Practice Address - Country:US
Practice Address - Phone:098-604-2549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86393207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI11945Medicare UPIN
CAI11945Medicare UPIN