Provider Demographics
NPI:1598758807
Name:MOZDAB, LAILA (DO)
Entity Type:Individual
Prefix:
First Name:LAILA
Middle Name:
Last Name:MOZDAB
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAILA
Other - Middle Name:
Other - Last Name:MOZDAB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 1303
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1303
Mailing Address - Country:US
Mailing Address - Phone:912-538-5359
Mailing Address - Fax:912-538-5228
Practice Address - Street 1:1 MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-538-5359
Practice Address - Fax:912-538-5228
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044793207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000899874BMedicaid
GAF63715Medicare UPIN
GA000899874BMedicaid