Provider Demographics
NPI:1962592907
Name:ELDICK, MOUSTAFA M (MD)
Entity type:Individual
Prefix:DR
First Name:MOUSTAFA
Middle Name:M
Last Name:ELDICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:899 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112-2109
Mailing Address - Country:US
Mailing Address - Phone:386-698-1088
Mailing Address - Fax:386-698-1099
Practice Address - Street 1:899 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-2109
Practice Address - Country:US
Practice Address - Phone:386-698-1088
Practice Address - Fax:386-698-1099
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25082YMedicare PIN