Basic Information
| Provider Information | |||||||||
| NPI: | 1396778189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOUANOUTOUA | ||||||||
| FirstName: | MOUATOU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Practice Location | |||||||||
| Address1: | 2335 E KASHIAN LN STE 240 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937012211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593200545 | ||||||||
| FaxNumber: | 5593200550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A90873 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | A90873 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | A90873 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 00A908730 | 05 | CA | MEDICAID |