Provider Demographics
NPI:1932146339
Name:MOALLEM, ANITA GROSS (MD)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:GROSS
Last Name:MOALLEM
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 1:560 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5027
Mailing Address - Country:US
Mailing Address - Phone:516-933-2800
Mailing Address - Fax:516-933-2809
Practice Address - Street 1:4355 147TH ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1736
Practice Address - Country:US
Practice Address - Phone:718-762-0900
Practice Address - Fax:718-886-5659
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095345174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10459014OtherCAQH
NY00549293Medicaid
NYB14233Medicare UPIN
NY40A181Medicare ID - Type Unspecified