Basic Information
| Provider Information | |||||||||
| NPI: | 1598758807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOZDAB | ||||||||
| FirstName: | LAILA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MOZDAB | ||||||||
| OtherFirstName: | LAILA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1303 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304751303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125385359 | ||||||||
| FaxNumber: | 9125385228 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEADOWS PKWY | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125385359 | ||||||||
| FaxNumber: | 9125385228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 044793 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000899874B | 05 | GA | MEDICAID |