Basic Information
| Provider Information | |||||||||
| NPI: | 1558357780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISSA | ||||||||
| FirstName: | MOISES | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330243624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549839191 | ||||||||
| FaxNumber: | 9549831152 | ||||||||
| Practice Location | |||||||||
| Address1: | 2488 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330243624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549839191 | ||||||||
| FaxNumber: | 9549831152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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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 | 207R00000X | ME81676 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 262300500 | 05 | FL | MEDICAID |