Provider Demographics
NPI:1306987474
Name:MOAZAM, MUSTAFA MOHAMMED (MD)
Entity type:Individual
Prefix:DR
First Name:MUSTAFA
Middle Name:MOHAMMED
Last Name:MOAZAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:14470 HORIZON BLVD
Mailing Address - Street 2:SUITE J
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-7695
Mailing Address - Country:US
Mailing Address - Phone:915-852-3225
Mailing Address - Fax:915-209-8289
Practice Address - Street 1:14470 HORIZON BLVD STE J
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79928-7696
Practice Address - Country:US
Practice Address - Phone:832-940-7071
Practice Address - Fax:877-761-6002
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2024-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXN6499208000000X, 2080P0207X, 2084P0800X, 2084P0804X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218754401Medicaid
TX218754401Medicaid