Provider Demographics
NPI:1831416742
Name:SHAHATIT, BASHAR MOUSA (MD)
Entity type:Individual
Prefix:
First Name:BASHAR
Middle Name:MOUSA
Last Name:SHAHATIT
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 1:19341 BEAR VALLEY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-5152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19341 BEAR VALLEY RD STE 104
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-5152
Practice Address - Country:US
Practice Address - Phone:760-956-4148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-02
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine