Provider Demographics
NPI:1669478681
Name:MOOSA, MAHMOOD FATTOOH (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHMOOD
Middle Name:FATTOOH
Last Name:MOOSA
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 1:15506 S TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-5520
Mailing Address - Country:US
Mailing Address - Phone:734-682-5243
Mailing Address - Fax:888-677-1987
Practice Address - Street 1:15506 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-5520
Practice Address - Country:US
Practice Address - Phone:734-682-5243
Practice Address - Fax:888-677-1987
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067199207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2158454Medicaid
OH0899941Medicare ID - Type Unspecified
OH2158454Medicaid