Healthcare Provider Details

I. General information

NPI: 1760418149
Provider Name (Legal Business Name): HOSAM MOUSTAFA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BASTANCHURY RD STE 130
FULLERTON CA
92835-3423
US

IV. Provider business mailing address

301 W BASTANCHURY RD STE 130
FULLERTON CA
92835-3423
US

V. Phone/Fax

Practice location:
  • Phone: 714-278-9363
  • Fax: 714-278-9364
Mailing address:
  • Phone: 714-278-9363
  • Fax: 714-278-9364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA71010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: