Provider Demographics
NPI:1932527017
Name:MOOSA, ADILLS (DO)
Entity type:Individual
Prefix:
First Name:ADILLS
Middle Name:
Last Name:MOOSA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-7803
Mailing Address - Country:US
Mailing Address - Phone:219-879-5400
Mailing Address - Fax:219-879-5900
Practice Address - Street 1:1750 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3803
Practice Address - Country:US
Practice Address - Phone:217-464-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-106492083X0100X
390200000X
IN02005491A2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program