Healthcare Provider Details

I. General information

NPI: 1386804052
Provider Name (Legal Business Name): ANGELA LOUISE MOUHLAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 SW 160TH AVE STE 250 SUITE 1000
MIRAMAR FL
33027-6314
US

IV. Provider business mailing address

880 KEMPSVILLE RD SUITE 1000
NORFOLK VA
23502-3931
US

V. Phone/Fax

Practice location:
  • Phone: 877-866-7123
  • Fax:
Mailing address:
  • Phone: 757-261-5000
  • Fax: 757-962-5610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101252624
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number263636
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0101252624
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: