Basic Information
| Provider Information | |||||||||
| NPI: | 1184607277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOMOH | ||||||||
| FirstName: | MUSA | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12150 ANNAPOLIS RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | GLENN DALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207699183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018051103 | ||||||||
| FaxNumber: | 3018051104 | ||||||||
| Practice Location | |||||||||
| Address1: | 12150 ANNAPOLIS RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | GLENN DALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207699183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018051103 | ||||||||
| FaxNumber: | 3018051104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 09/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D52900 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 883910701 | 05 | MD | MEDICAID |