Basic Information
| Provider Information | |||||||||
| NPI: | 1083354807 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUSETTE MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7001 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913577001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887815 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 SANTA MONICA BLVD STE 724E | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108299060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2022 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | MOUSETTE | ||||||||
| AuthorizedOfficialFirstName: | ALYSE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8188887815 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M. D. | ||||||||
| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.