Provider Demographics
NPI:1497797807
Name:MOUSSA, NOUHAD YACOUB (MD)
Entity Type:Individual
Prefix:
First Name:NOUHAD
Middle Name:YACOUB
Last Name:MOUSSA
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:PO BOX 64568
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-4568
Mailing Address - Country:US
Mailing Address - Phone:318-424-5449
Mailing Address - Fax:855-230-1466
Practice Address - Street 1:3301 W GANDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2931
Practice Address - Country:US
Practice Address - Phone:813-925-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68141208000000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26902OtherBLUE CROSS OF FLORIDA
FL101288OtherAMERIGROUP
FL377492900Medicaid
FLF47163Medicare UPIN
930069944Medicare PIN
FL26902UMedicare PIN