Provider Demographics
NPI:1073512976
Name:MUSSO, LOUIS A (DO)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:A
Last Name:MUSSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1520 E HAMMER LN
Mailing Address - Street 2:STE. 104
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6664
Mailing Address - Country:US
Mailing Address - Phone:928-768-1200
Mailing Address - Fax:928-768-1209
Practice Address - Street 1:1520 E HAMMER LN
Practice Address - Street 2:SUITE 104
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6664
Practice Address - Country:US
Practice Address - Phone:928-768-1200
Practice Address - Fax:928-768-1209
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI49240208600000X, 2086S0129X
AZ5566208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ089437Medicaid
WIH98274Medicare UPIN