Healthcare Provider Details

I. General information

NPI: 1366964678
Provider Name (Legal Business Name): SAMEET MOOR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16888 BASELINE AVE
FONTANA CA
92336-2083
US

IV. Provider business mailing address

903 W MARTIN ST # MS 49-2
SAN ANTONIO TX
78207-0903
US

V. Phone/Fax

Practice location:
  • Phone: 855-422-8029
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number23084
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR10992
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR10992
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23084
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: