Provider Demographics
NPI:1336185800
Name:MOOSA, AMOD S (MD)
Entity Type:Individual
Prefix:
First Name:AMOD
Middle Name:S
Last Name:MOOSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:90743-0303
Mailing Address - Country:US
Mailing Address - Phone:714-375-6280
Mailing Address - Fax:714-941-7661
Practice Address - Street 1:3630 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2636
Practice Address - Country:US
Practice Address - Phone:310-900-2005
Practice Address - Fax:714-841-7661
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA246832080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A246830Medicaid