Provider Demographics
NPI:1346261369
Name:MOUALLEM, RAJA M (MD)
Entity Type:Individual
Prefix:
First Name:RAJA
Middle Name:M
Last Name:MOUALLEM
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 1:200 HENRY CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5720
Mailing Address - Country:US
Mailing Address - Phone:504-412-1835
Mailing Address - Fax:
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5720
Practice Address - Country:US
Practice Address - Phone:504-412-1835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0118072080P0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09672573Medicaid
LA1330990Medicaid
LA1330990Medicaid
MS09672573Medicaid
LA5M585F669Medicare PIN