Provider Demographics
NPI:1164419834
Name:AOUTHMANY, MOUSTAFA M (MD)
Entity Type:Individual
Prefix:
First Name:MOUSTAFA
Middle Name:M
Last Name:AOUTHMANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636
Practice Address - Country:US
Practice Address - Phone:559-353-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350656142080N0001X
IN01074192A2080N0001X
CAC1459112080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000965558OtherBCBS MFM
OH0225778Medicaid
IN201258820Medicaid
000000965541OtherBCBS NICU