Healthcare Provider Details

I. General information

NPI: 1144634510
Provider Name (Legal Business Name): JOSEPHINE MOUKHTAR M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 ORCHARD AVE APT 1
GLENDALE CA
91206-4179
US

IV. Provider business mailing address

1816 ORCHARD AVE APT 1
GLENDALE CA
91206-4179
US

V. Phone/Fax

Practice location:
  • Phone: 818-543-1663
  • Fax:
Mailing address:
  • Phone: 818-543-1663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA42174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: