Provider Demographics
NPI:1912907197
Name:MOUSSOUTTAS, MICHAEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:MOUSSOUTTAS
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 1:4755 OGLETOWN STANTON RD STE 2E99
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:856-630-2406
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 2E99
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2559
Practice Address - Country:US
Practice Address - Phone:302-733-5982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4327842084V0102X, 2084N0400X
NY2012942084N0400X
NJ25MA076588002084N0400X, 2084V0102X
NJNCC00372-082084A2900X
PANCC00372-082084A2900X
DEC1-00122922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018727880005Medicaid
NJ2095572Medicaid
H21872Medicare UPIN
NJ2095572Medicaid
NY02S161Medicare ID - Type Unspecified
NJ2095572Medicaid