Healthcare Provider Details

I. General information

NPI: 1235170192
Provider Name (Legal Business Name): MOUSA I DABABNAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 RITTER DR
BEAVER WV
25813-9513
US

IV. Provider business mailing address

856 RITTER DR P.O. BOX 247
BEAVER WV
25813-9513
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-4845
  • Fax: 304-255-4845
Mailing address:
  • Phone: 304-255-4845
  • Fax: 304-255-4845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10670
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: