Provider Demographics
NPI:1295732121
Name:ISSA, MAHMOUD A (MD)
Entity type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:A
Last Name:ISSA
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 1:224 MEMORIAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6332
Mailing Address - Country:US
Mailing Address - Phone:910-577-1444
Mailing Address - Fax:910-577-1001
Practice Address - Street 1:224 MEMORIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6332
Practice Address - Country:US
Practice Address - Phone:910-577-1444
Practice Address - Fax:910-577-1001
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-11-14
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-07
Provider Licenses
StateLicense IDTaxonomies
NC22581174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901890Medicaid
NC8901890Medicaid
NC201988Medicare PIN