Provider Demographics
NPI:1548339146
Name:GOOVA, MOUZA
Entity type:Individual
Prefix:
First Name:MOUZA
Middle Name:
Last Name:GOOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 YADKIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-3449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 YADKIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3449
Practice Address - Country:US
Practice Address - Phone:980-323-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01065208600000X
PAMD439730208600000X
VA0101252418208600000X
IN01075863A208600000X
KY42093208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000894663OtherANTHEM BLUE CROSS BLUE SHIELD
KY7100053480Medicaid
KYK164530Medicare PIN
KY000000894663OtherANTHEM BLUE CROSS BLUE SHIELD