Provider Demographics
NPI:1619483245
Name:MOUSSA, JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
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 1:5130 SUNFOREST DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6327
Mailing Address - Country:US
Mailing Address - Phone:941-210-4570
Mailing Address - Fax:941-210-4590
Practice Address - Street 1:2415 UNIVERSITY PKWY STE 112
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2809
Practice Address - Country:US
Practice Address - Phone:941-210-4570
Practice Address - Fax:941-210-4570
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308632207R00000X
FLME155089207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114487500Medicaid