MEDICARE: DR. BINUSHA MOITHEENNAZIMA 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	207RP1001X	Pulmonary Disease Physician	N5256	TX
2	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	N5256	TX
3	207RS0012X	Sleep Medicine (Internal Medicine) Physician	N5256	TX

General Provider Information

NPI Number	:	1760658330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BINUSHA MOITHEENNAZIMA MD

Provider Business Mailing Address
First Line	:	PO BOX 631310
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75963-1310
Country	:	US
Telephone Number	:	936-585-4646
Fax Number	:	936-585-4645

Provider Business Practice Location Address
First Line	:	1209 N MOUND ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4028
Country	:	US
Telephone Number	:	936-585-4646
Fax Number	:	936-585-4645

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

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	09/12/2011

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