Basic Information
| Provider Information | |||||||||
| NPI: | 1205887213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALSHAZLEY | ||||||||
| FirstName: | MOUDAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 WOODBINE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325718790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509946575 | ||||||||
| FaxNumber: | 8509945643 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 WOODBINE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325718790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509946575 | ||||||||
| FaxNumber: | 8509945643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2006 | ||||||||
| LastUpdateDate: | 02/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME78728 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | ME78728 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 263433300 | 05 | FL | MEDICAID |