Provider Demographics
NPI:1184623555
Name:BATEH, MOUSA R (DPM)
Entity type:Individual
Prefix:DR
First Name:MOUSA
Middle Name:R
Last Name:BATEH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W MONROE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1177
Mailing Address - Country:US
Mailing Address - Phone:904-384-2240
Mailing Address - Fax:904-384-6055
Practice Address - Street 1:3550 UNIVERSITY BLVD S
Practice Address - Street 2:STE 204
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4246
Practice Address - Country:US
Practice Address - Phone:904-384-2240
Practice Address - Fax:904-448-0030
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3191213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340528100Medicaid
FLV05430Medicare UPIN
FLU4775AMedicare PIN