Provider Demographics
NPI:1407933302
Name:MOUSSA, ISSAM D (MD)
Entity Type:Individual
Prefix:DR
First Name:ISSAM
Middle Name:D
Last Name:MOUSSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ISSAM
Other - Middle Name:
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 551308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1308
Mailing Address - Country:US
Mailing Address - Phone:904-493-3333
Mailing Address - Fax:904-493-2222
Practice Address - Street 1:7011 A C SKINNER PKWY
Practice Address - Street 2:SUITE 160
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6954
Practice Address - Country:US
Practice Address - Phone:904-493-3333
Practice Address - Fax:904-493-2222
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL109466207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003671100Medicaid
FL003671100Medicaid
FL14E1KMedicare PIN
NY32N421Medicare ID - Type Unspecified
FL003671100Medicaid