Healthcare Provider Details

I. General information

NPI: 1588127757
Provider Name (Legal Business Name): MOUSTAPHA ABIDALI DO PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 01/12/2025
Certification Date: 01/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 W FOOTHILL BLVD
GLENDORA CA
91741-5309
US

IV. Provider business mailing address

12223 HIGHLAND AVE STE 106-526
RANCHO CUCAMONGA CA
91739-2574
US

V. Phone/Fax

Practice location:
  • Phone: 269-145-2196
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MOUSTAPHA ABIDALI
Title or Position: CEO
Credential: DO
Phone: 480-251-4030