Provider Demographics
NPI:1629482740
Name:MOUSSALY, ELIAS (MD)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:
Last Name:MOUSSALY
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:337-470-2739
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4809 AMBASSADOR CAFFERY PKWY STE 230
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-8800
Practice Address - Country:US
Practice Address - Phone:337-470-2739
Practice Address - Fax:337-235-5474
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2022-06-30
Deactivation Date:2015-01-20
Deactivation Code:
Reactivation Date:2015-03-10
Provider Licenses
StateLicense IDTaxonomies
LA324286207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2553739Medicaid