Provider Demographics
NPI:1407811193
Name:MOUSA, MOUSA ELHAMMALI (MD)
Entity Type:Individual
Prefix:DR
First Name:MOUSA
Middle Name:ELHAMMALI
Last Name:MOUSA
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 1:1136 CLEVELAND AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3618
Mailing Address - Country:US
Mailing Address - Phone:404-762-6140
Mailing Address - Fax:404-762-7922
Practice Address - Street 1:1136 CLEVELAND AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3618
Practice Address - Country:US
Practice Address - Phone:404-762-6140
Practice Address - Fax:404-762-7922
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA03574207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000590554JMedicaid
GA00590554DMedicaid
GA06BDGMFMedicare PIN
GAF72179Medicare UPIN
F72179Medicare UPIN
GA00590554DMedicaid