Basic Information
| Provider Information | |||||||||
| NPI: | 1710046396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSCOSO | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | FRANCISCO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST | ||||||||
| Address2: | 3RD FLOOR PHR SYSTEMS | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264053640 | ||||||||
| FaxNumber: | 6264056768 | ||||||||
| Practice Location | |||||||||
| Address1: | 13652 CANTARA ST | ||||||||
| Address2: | |||||||||
| City: | PANORAMA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914025423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183752000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207YX0007X | G86605 | CA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 00G866050 | 05 | CA | MEDICAID |