Provider Demographics
NPI:1457387151
Name:MOOSSAVI, LEYLA (MD)
Entity type:Individual
Prefix:
First Name:LEYLA
Middle Name:
Last Name:MOOSSAVI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 E BROOMFIELD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-5427
Mailing Address - Country:US
Mailing Address - Phone:989-775-7492
Mailing Address - Fax:989-775-6892
Practice Address - Street 1:1621 E BROOMFIELD ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-5427
Practice Address - Country:US
Practice Address - Phone:989-775-7492
Practice Address - Fax:989-775-6892
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065333207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1603700871OtherBCBSM
MI200000005818OtherPHP COMMERCIAL
MI4711889Medicaid
MI1006844OtherMCLAREN HEALTH PLAN
MI0986427OtherHEALTHPLUS COMMERCIAL
MI1006843OtherMCLAREN HEALTH PLAN
MI4349365Medicaid
MI238618Medicare Oscar/Certification
MI160044647Medicare PIN
MI1006843OtherMCLAREN HEALTH PLAN
MI1603700871OtherBCBSM