Provider Demographics
NPI:1003465915
Name:MOAZAM PA
Entity Type:Organization
Organization Name:MOAZAM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MUSTAFA
Authorized Official - Middle Name:MOHAMMED
Authorized Official - Last Name:MOAZAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-691-9129
Mailing Address - Street 1:7106 SPENCER HWY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-1806
Mailing Address - Country:US
Mailing Address - Phone:918-691-9129
Mailing Address - Fax:
Practice Address - Street 1:7106 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-1806
Practice Address - Country:US
Practice Address - Phone:918-691-9129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX298010404Medicaid