Provider Demographics
NPI:1659307775
Name:MOUSA, OMAIMA (MD)
Entity Type:Individual
Prefix:
First Name:OMAIMA
Middle Name:
Last Name:MOUSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8880 NAVARRE PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-3613
Mailing Address - Country:US
Mailing Address - Phone:850-939-5550
Mailing Address - Fax:850-939-5445
Practice Address - Street 1:8880 NAVARRE PKWY STE 102
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-3613
Practice Address - Country:US
Practice Address - Phone:850-939-5550
Practice Address - Fax:850-939-5445
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME875662080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268996100Medicaid
FL81080OtherBLUE CROSS BLUE SHIELD OF FLORIDA
AL591-68789OtherBLUE CROSS BLUE SHIELD OF ALABAM
FLAC177ZMedicare PIN
FL268996100Medicaid