Provider Demographics
NPI:1548552375
Name:ABDALLA, MUSA (M D)
Entity type:Individual
Prefix:
First Name:MUSA
Middle Name:
Last Name:ABDALLA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 W JEFFERSON BLVD PMB 109
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-344-4035
Mailing Address - Fax:260-969-9272
Practice Address - Street 1:2500 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1158
Practice Address - Country:US
Practice Address - Phone:260-463-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073617A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201096160Medicaid
IN201096160Medicaid