Provider Demographics
NPI:1306264023
Name:MOSSA-BASHA, MALIK (MD)
Entity type:Individual
Prefix:
First Name:MALIK
Middle Name:
Last Name:MOSSA-BASHA
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 1:9998 CROSSPOINT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3307
Mailing Address - Country:US
Mailing Address - Phone:317-579-2150
Mailing Address - Fax:317-579-2130
Practice Address - Street 1:9998 CROSSPOINT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3307
Practice Address - Country:US
Practice Address - Phone:317-579-2150
Practice Address - Fax:317-579-2130
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01089176A2085R0202X
MDD886542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI43015045720OtherSTATE LICENSE
MDD88654OtherLICENSE
IN01089176AOtherSTATE LICENSE