Healthcare Provider Details

I. General information

NPI: 1639913403
Provider Name (Legal Business Name): RAED MOUSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 STATE ST STE 201
ERIE PA
16507-1429
US

IV. Provider business mailing address

1416 DRAKE DR
ERIE PA
16505-2604
US

V. Phone/Fax

Practice location:
  • Phone: 814-456-4241
  • Fax:
Mailing address:
  • Phone: 814-582-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD487376
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: