Healthcare Provider Details

I. General information

NPI: 1053308742
Provider Name (Legal Business Name): IOANNIS A. MOISSIDIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: JOHN A. MOISSIDIS MD

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 OLIVE ST SUITE B
SHREVEPORT LA
71104-2162
US

IV. Provider business mailing address

850 OLIVE ST SUITE B
SHREVEPORT LA
71104-2162
US

V. Phone/Fax

Practice location:
  • Phone: 318-221-3584
  • Fax: 318-227-9094
Mailing address:
  • Phone: 318-221-3584
  • Fax: 318-227-9094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number14718R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: