Provider Demographics
NPI:1437484573
Name:MOOSABHOY, MUFADAL AMMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:MUFADAL
Middle Name:AMMAR
Last Name:MOOSABHOY
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 1:205 68TH ST
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-3920
Mailing Address - Country:US
Mailing Address - Phone:708-369-9695
Mailing Address - Fax:
Practice Address - Street 1:5721 S MARYLAND AVE
Practice Address - Street 2:K-155
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1425
Practice Address - Country:US
Practice Address - Phone:773-702-6435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125056396208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics