Healthcare Provider Details

I. General information

NPI: 1265493217
Provider Name (Legal Business Name): MOOSA M LUNAT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 E YOSEMITE AVE SUITE B
MANTECA CA
95336-5011
US

IV. Provider business mailing address

1191 E YOSEMITE AVE SUITE B
MANTECA CA
95336-5011
US

V. Phone/Fax

Practice location:
  • Phone: 209-823-8158
  • Fax: 209-823-6186
Mailing address:
  • Phone: 209-823-8158
  • Fax: 209-823-6186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA32534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: