Healthcare Provider Details

I. General information

NPI: 1962448431
Provider Name (Legal Business Name): MOOSSA HEIKALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18065 VENTURA BLVD
ENCINO CA
91316-3517
US

IV. Provider business mailing address

P.O. BOX 49911
LOS ANGELES CA
90049-4911
US

V. Phone/Fax

Practice location:
  • Phone: 818-708-6163
  • Fax: 818-344-1390
Mailing address:
  • Phone: 818-708-6163
  • Fax: 818-708-6167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA40559
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: