Healthcare Provider Details

I. General information

NPI: 1962592907
Provider Name (Legal Business Name): MOUSTAFA M ELDICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 N SUMMIT ST
CRESCENT CITY FL
32112-2109
US

IV. Provider business mailing address

899 N SUMMIT ST
CRESCENT CITY FL
32112-2109
US

V. Phone/Fax

Practice location:
  • Phone: 386-698-1088
  • Fax: 386-698-1099
Mailing address:
  • Phone: 386-698-1088
  • Fax: 386-698-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0064833
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: