Healthcare Provider Details

I. General information

NPI: 1992116982
Provider Name (Legal Business Name): MOUSA MATAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 CENTRAL AVE STE 106
RIVERSIDE CA
92506-2930
US

IV. Provider business mailing address

4100 CENTRAL AVE STE 106
RIVERSIDE CA
92506-2930
US

V. Phone/Fax

Practice location:
  • Phone: 951-750-1090
  • Fax: 951-750-1091
Mailing address:
  • Phone: 951-750-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number67430
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA167764
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA167764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: