Provider Demographics
NPI:1922116631
Name:MOUSSA, KHALID MOHAMED (MD)
Entity Type:Individual
Prefix:
First Name:KHALID
Middle Name:MOHAMED
Last Name:MOUSSA
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 1:550 REDSTONE AVE W
Mailing Address - Street 2:STE. 430
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6428
Mailing Address - Country:US
Mailing Address - Phone:850-398-8605
Mailing Address - Fax:850-398-8610
Practice Address - Street 1:550 REDSTONE AVE W
Practice Address - Street 2:STE. 430
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6428
Practice Address - Country:US
Practice Address - Phone:850-398-8605
Practice Address - Fax:850-398-8610
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036527207RG0100X
LAMD201030207RG0100X
FLME100573207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010519800Medicaid
LA1099058Medicaid
LA4K397Medicare PIN
FL010519800Medicaid
LA4K3976629Medicare PIN
H14198Medicare UPIN