Provider Demographics
NPI:1205887213
Name:ALSHAZLEY, MOUDAR (MD)
Entity type:Individual
Prefix:
First Name:MOUDAR
Middle Name:
Last Name:ALSHAZLEY
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 1:4225 WOODBINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8790
Mailing Address - Country:US
Mailing Address - Phone:850-994-6575
Mailing Address - Fax:850-994-5643
Practice Address - Street 1:4225 WOODBINE RD
Practice Address - Street 2:SUITE A
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8790
Practice Address - Country:US
Practice Address - Phone:850-994-6575
Practice Address - Fax:850-994-5643
Is Sole Proprietor?:No
Enumeration Date:2006-05-14
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78728207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263433300Medicaid
FL263433300Medicaid
FLG20630Medicare UPIN
FL13265AMedicare ID - Type Unspecified