Provider Demographics
NPI:1164586558
Name:MOAWAD, STEPHANIE A (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:MOAWAD
Suffix:
Gender:F
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:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-334-0206
Mailing Address - Fax:352-334-4041
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-334-0206
Practice Address - Fax:352-334-4041
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-087012208000000X
FLME106579208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2670999Medicaid
FL002796500Medicaid
FLDX191ZMedicare PIN