Provider Demographics
NPI:1306178256
Name:MOUSSA, MOTAZ (MD)
Entity type:Individual
Prefix:
First Name:MOTAZ
Middle Name:
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:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:410 LIONEL WAY STE 201
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-7809
Practice Address - Country:US
Practice Address - Phone:863-422-5331
Practice Address - Fax:863-422-5336
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.129093207RC0000X, 207RI0011X
FLME156847207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0175394Medicaid
OHP01784682OtherRAILROAD MEDICARE - MHCPI
OHH479820Medicare PIN
OH0175394Medicaid