Provider Demographics
NPI:1780799981
Name:MAALOUF, MOUSA (MD)
Entity type:Individual
Prefix:DR
First Name:MOUSA
Middle Name:
Last Name:MAALOUF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOUSA
Other - Middle Name:
Other - Last Name:MAALOUF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-864-8454
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-864-6629
Practice Address - Fax:228-864-6669
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16101207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119774Medicaid
MS110174412OtherRAILROAD MEDICARE
MSP00722705OtherRAILROAD MEDICARE
MS00119774Medicaid
MS110174412OtherRAILROAD MEDICARE
MS00119774Medicaid
MSG82670Medicare UPIN
MS110001118Medicare ID - Type Unspecified
MS$$$$$$$$$GOtherBCBS