Provider Demographics
NPI:1548471493
Name:MOUSSA, MOHAMAD A (MD)
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:A
Last Name:MOUSSA
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 1:4510 DORR ST # MS 840
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4040
Mailing Address - Country:US
Mailing Address - Phone:419-383-5334
Mailing Address - Fax:
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084214207PH0002X
OH35.092517207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000595930OtherANTHEM BCBS
OH2943588Medicaid
OH2943588Medicaid