Provider Demographics
NPI:1730348830
Name:BASSAM MOUAZZEN M.D., P.C.
Entity type:Organization
Organization Name:BASSAM MOUAZZEN M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUAZZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-852-9986
Mailing Address - Street 1:PO BOX 1939
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-1939
Mailing Address - Country:US
Mailing Address - Phone:626-852-9986
Mailing Address - Fax:
Practice Address - Street 1:415 W ROUTE 66
Practice Address - Street 2:SUITE 101
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4335
Practice Address - Country:US
Practice Address - Phone:626-852-9986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43066207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C430661Medicaid
CA00C430661Medicaid