=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972790228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABDUL R MOOSA MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 07/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 W FAIRMONT PKWY SUITE # D
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77571-6307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-470-4740
-----------------------------------------------------
Fax | 281-470-4733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 W FAIRMONT PKWY SUITE # D
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77571-6307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-470-4740
-----------------------------------------------------
Fax | 281-470-4733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. ABDUL R MOOSA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 281-470-4740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | J3015
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------