Provider Demographics
NPI:1659577369
Name:A S MOOSA MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:A S MOOSA MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMOD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-375-6280
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:90743-0303
Mailing Address - Country:US
Mailing Address - Phone:714-375-6280
Mailing Address - Fax:
Practice Address - Street 1:3630 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2609
Practice Address - Country:US
Practice Address - Phone:310-900-2005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA2468302080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0062660Medicaid