Healthcare Provider Details

I. General information

NPI: 1689627879
Provider Name (Legal Business Name): MONIF MOUSSA MATOUK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W I ST STE C
LOS BANOS CA
93635-3459
US

IV. Provider business mailing address

311 W I ST
LOS BANOS CA
93635-3479
US

V. Phone/Fax

Practice location:
  • Phone: 209-827-2766
  • Fax:
Mailing address:
  • Phone: 209-826-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016005096
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5321
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5321
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: