Provider Demographics
NPI:1841630191
Name:MOOSAVI, MESUM (MD)
Entity type:Individual
Prefix:DR
First Name:MESUM
Middle Name:
Last Name:MOOSAVI
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 1:830 MORRIS TPKE FL 4
Mailing Address - Street 2:
Mailing Address - City:SHORT HILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07078-2625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:290 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-1961
Practice Address - Country:US
Practice Address - Phone:856-266-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2023-08-23
Deactivation Date:2017-10-18
Deactivation Code:
Reactivation Date:2017-12-13
Provider Licenses
StateLicense IDTaxonomies
AZR73958208600000X
NJ25MA10937100208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery