Provider Demographics
NPI:1730132200
Name:MOUALLEM, DAVID PETER (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:PETER
Last Name:MOUALLEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NANTICOKE
Mailing Address - State:PA
Mailing Address - Zip Code:18634-1602
Mailing Address - Country:US
Mailing Address - Phone:570-258-3939
Mailing Address - Fax:570-258-0165
Practice Address - Street 1:4 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NANTICOKE
Practice Address - State:PA
Practice Address - Zip Code:18634-1602
Practice Address - Country:US
Practice Address - Phone:570-735-7474
Practice Address - Fax:570-735-2921
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007906L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015426480004Medicaid
PA002460OtherFIRST PRIORITY HEALTH
PA20815OtherGEISINGER HEALTH PLAN
PA787165OtherHIGHMARK BLUE SHIELD
PA787165OtherFIRST PRIORITY LIFE
PA129122OtherHEALTH AMERICA
PA020017400OtherBLACK LUNG
PA787165OtherHIGHMARK BLUE SHIELD
PA0015426480004Medicaid