Basic Information
| Provider Information | |||||||||
| NPI: | 1821083338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOUSA | ||||||||
| FirstName: | HAYAT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | MC5003 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583096300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8110 BIRMINGHAM WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589664003 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 35065608 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080P0206X | C 137969 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0108724000 | 05 | WV | MEDICAID | 0932772 | 05 | OH | MEDICAID | 64964240 | 05 | KY | MEDICAID | MO0890502 | 01 | OH | MEDICARE | OTHER |