Healthcare Provider Details

I. General information

NPI: 1982051371
Provider Name (Legal Business Name): SARA MOUSA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 INDIANA AVE
LUBBOCK TX
79415-3364
US

IV. Provider business mailing address

3601 4TH ST STOP 6211
LUBBOCK TX
79430-0002
US

V. Phone/Fax

Practice location:
  • Phone: 806-761-0878
  • Fax: 806-472-6802
Mailing address:
  • Phone: 806-743-2978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberS4532
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: