MEDICARE: IOANNIS A. MOISSIDIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	14718R	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053308742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IOANNIS A. MOISSIDIS MD

Provider Business Mailing Address
First Line	:	850 OLIVE ST
Second Line	:	SUITE B
City	:	SHREVEPORT
State	:	LA
Zip	:	71104-2162
Country	:	US
Telephone Number	:	318-221-3584
Fax Number	:	318-227-9094

Provider Business Practice Location Address
First Line	:	850 OLIVE ST
Second Line	:	SUITE B
City	:	SHREVEPORT
State	:	LA
Zip	:	71104-2162
Country	:	US
Telephone Number	:	318-221-3584
Fax Number	:	318-227-9094

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	07/08/2007

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Directions to “ IOANNIS A. MOISSIDIS MD” Practice Location

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