MEDICARE: BASHAR MOUSA SHAHATIT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A122792	CA

General Provider Information

NPI Number	:	1831416742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BASHAR MOUSA SHAHATIT M.D.

Provider Business Mailing Address
First Line	:	19341 BEAR VALLEY RD STE 104
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-5152
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19341 BEAR VALLEY RD STE 104
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-5152
Country	:	US
Telephone Number	:	760-956-4148
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2010
Last Update Date	:	11/10/2021

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