Healthcare Provider Details

I. General information

NPI: 1629482740
Provider Name (Legal Business Name): ELIAS MOUSSALY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date: 01/20/2015
Reactivation Date: 03/10/2015

III. Provider practice location address

4809 AMBASSADOR CAFFERY PKWY STE 230
LAFAYETTE LA
70508-8800
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-2739
  • Fax: 337-235-5474
Mailing address:
  • Phone: 337-470-2739
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number324286
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: