Provider Demographics
NPI:1053308742
Name:MOISSIDIS, IOANNIS A (MD)
Entity Type:Individual
Prefix:
First Name:IOANNIS
Middle Name:A
Last Name:MOISSIDIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:A
Other - Last Name:MOISSIDIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:850 OLIVE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2162
Mailing Address - Country:US
Mailing Address - Phone:318-221-3584
Mailing Address - Fax:318-227-9094
Practice Address - Street 1:850 OLIVE ST
Practice Address - Street 2:SUITE B
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2162
Practice Address - Country:US
Practice Address - Phone:318-221-3584
Practice Address - Fax:318-227-9094
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14718R207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053716Medicaid
LA1053716Medicaid
4J186Medicare ID - Type Unspecified