Healthcare Provider Details

I. General information

NPI: 1912907197
Provider Name (Legal Business Name): MICHAEL M MOUSSOUTTAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD STE 2E99
NEWARK DE
19718-2559
US

IV. Provider business mailing address

4755 OGLETOWN STANTON RD STE 2E99
NEWARK DE
19718-2200
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-5982
  • Fax:
Mailing address:
  • Phone: 856-630-2406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberMD432784
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number201294
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25MA07658800
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License NumberNCC00372-08
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License NumberNCC00372-08
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number25MA07658800
License Number StateNJ
# 7
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD432784
License Number StatePA
# 8
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberC1-0012292
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: