Provider Demographics
NPI:1730347030
Name:FOSTER-MOUMOUTJIS, GINA M (MD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:FOSTER-MOUMOUTJIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-1760
Mailing Address - Fax:
Practice Address - Street 1:3600 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2709
Practice Address - Country:US
Practice Address - Phone:954-262-1860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME125729207Q00000X
CAA113319207Q00000X
NY251998-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000695941Medicaid
NYW6L111Medicare PIN
NY331952Medicare PIN