Basic Information
| Provider Information | |||||||||
| NPI: | 1639705528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOUCRI | ||||||||
| FirstName: | BASSEM | ||||||||
| MiddleName: | MERIT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | MDCC 22-315 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900953075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108256244 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | MDCC 22-315 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900953075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108256244 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2020 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | PTL3720 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PTL3720 | 01 | CA | CA STATE MEDICAL LICENSE | OTHER |