Provider Demographics
NPI:1205189792
Name:MASOUD, MOADH
Entity Type:Individual
Prefix:
First Name:MOADH
Middle Name:
Last Name:MASOUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6729 PIMA DR APT 202
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-5669
Mailing Address - Country:US
Mailing Address - Phone:414-840-4393
Mailing Address - Fax:
Practice Address - Street 1:6729 PIMA DR APT 202
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-5669
Practice Address - Country:US
Practice Address - Phone:414-840-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-21
Last Update Date:2012-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16755-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist