Healthcare Provider Details

I. General information

NPI: 1871793661
Provider Name (Legal Business Name): MOE ISSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1153 CENTRE ST
JAMAICA PLAIN MA
02130-3446
US

IV. Provider business mailing address

1153 CENTRE ST
JAMAICA PLAIN MA
02130-3446
US

V. Phone/Fax

Practice location:
  • Phone: 617-983-7000
  • Fax:
Mailing address:
  • Phone: 617-983-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number250424
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number250424
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number250424
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: