Healthcare Provider Details

I. General information

NPI: 1861613291
Provider Name (Legal Business Name): MATTHEW SAND MOSURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 LANDRY DRIVE
BOSSIER CITY LA
71111
US

IV. Provider business mailing address

1534 ELIZABETH AVE STE 301
SHREVEPORT LA
71101-4531
US

V. Phone/Fax

Practice location:
  • Phone: 318-752-7850
  • Fax: 318-752-7855
Mailing address:
  • Phone: 318-629-5001
  • Fax: 318-629-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number15597R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number15597R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: