Healthcare Provider Details

I. General information

NPI: 1194025221
Provider Name (Legal Business Name): MICHAEL EMEEL MOUSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 S CLOVIS AVE
FRESNO CA
93727-4254
US

IV. Provider business mailing address

228 S CLOVIS AVE
FRESNO CA
93727-4254
US

V. Phone/Fax

Practice location:
  • Phone: 714-801-8878
  • Fax:
Mailing address:
  • Phone: 714-801-8878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA136912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: