Provider Demographics
NPI:1487620035
Name:MOUSSALLI, CLARICE (MD)
Entity type:Individual
Prefix:DR
First Name:CLARICE
Middle Name:
Last Name:MOUSSALLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4374 NEW TOWN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2865
Mailing Address - Country:US
Mailing Address - Phone:757-259-1900
Mailing Address - Fax:757-259-1901
Practice Address - Street 1:4374 NEW TOWN AVE
Practice Address - Street 2:STE 100
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2865
Practice Address - Country:US
Practice Address - Phone:757-259-1900
Practice Address - Fax:757-259-1901
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010163927Medicaid
C87602Medicare UPIN
VA010163927Medicaid