Provider Demographics
NPI:1730170887
Name:BASHOURA, HABIB MOUSSA (MD)
Entity type:Individual
Prefix:MR
First Name:HABIB
Middle Name:MOUSSA
Last Name:BASHOURA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1234 FOOTHILL BLVD
Mailing Address - Street 2:#2
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3329
Mailing Address - Country:US
Mailing Address - Phone:909-596-4879
Mailing Address - Fax:909-596-9199
Practice Address - Street 1:1234 FOOTHILL BLVD
Practice Address - Street 2:#2
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3329
Practice Address - Country:US
Practice Address - Phone:909-596-4879
Practice Address - Fax:909-596-9199
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2016-12-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA52519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A55191Medicaid
CAA52519Medicare ID - Type Unspecified
CA00A55191Medicaid