Basic Information
| Provider Information | |||||||||
| NPI: | 1326003765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENASHA | ||||||||
| FirstName: | MOUSSA | ||||||||
| MiddleName: | YOUSSEF | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7068 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237070068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576863508 | ||||||||
| FaxNumber: | 7576860541 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEADE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234344259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575390251 | ||||||||
| FaxNumber: | 7579239626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 03/05/2013 | ||||||||
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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 | 207RG0100X | 0101036321 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 6095194 | 05 | VA | MEDICAID | 100002662 | 01 | VA | RAILROAD MEDICARE | OTHER | 890578F | 05 | NC | MEDICAID | 01497089 | 05 | NY | MEDICAID |