Healthcare Provider Details

I. General information

NPI: 1073512976
Provider Name (Legal Business Name): LOUIS A MUSSO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 E HAMMER LN SUITE 104
FORT MOHAVE AZ
86426-6664
US

IV. Provider business mailing address

1520 E HAMMER LN STE. 104
FORT MOHAVE AZ
86426-6664
US

V. Phone/Fax

Practice location:
  • Phone: 928-768-1200
  • Fax: 928-768-1209
Mailing address:
  • Phone: 928-768-1200
  • Fax: 928-768-1209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number49240
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number49240
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5566
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number5566
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: