Healthcare Provider Details

I. General information

NPI: 1003465915
Provider Name (Legal Business Name): MOAZAM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7106 SPENCER HWY
PASADENA TX
77505-1806
US

IV. Provider business mailing address

7106 SPENCER HWY
PASADENA TX
77505-1806
US

V. Phone/Fax

Practice location:
  • Phone: 918-691-9129
  • Fax:
Mailing address:
  • Phone: 918-691-9129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MUSTAFA MOHAMMED MOAZAM
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 918-691-9129