Basic Information
| Provider Information | |||||||||
| NPI: | 1609821107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAMONKI | ||||||||
| FirstName: | MOUSA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24DD5 WESTWOOD STATION | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107947274 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 MEDICAL PLAZA | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107947274 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 04/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | A95374 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | A95374 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00A953740 | 05 | CA | MEDICAID |