Provider Demographics
NPI:1194719807
Name:ABOU-SAMRA, MOUSTAPHA (MD)
Entity type:Individual
Prefix:
First Name:MOUSTAPHA
Middle Name:
Last Name:ABOU-SAMRA
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 1:168 N BRENT ST
Mailing Address - Street 2:STE 408
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2824
Mailing Address - Country:US
Mailing Address - Phone:805-643-2179
Mailing Address - Fax:805-643-0672
Practice Address - Street 1:168 N BRENT ST
Practice Address - Street 2:STE 408
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2824
Practice Address - Country:US
Practice Address - Phone:805-643-2179
Practice Address - Fax:805-643-0672
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36688207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A28162Medicare UPIN
A36688Medicare PIN