Basic Information
Provider Information | |||||||||
NPI: | 1912907197 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOUSSOUTTAS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4755 OGLETOWN STANTON RD STE 2E99 | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197182200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566302406 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4755 OGLETOWN STANTON RD STE 2E99 | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197182559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3027335982 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084V0102X | MD432784 | PA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084N0400X | 201294 | NY | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 25MA07658800 | NJ | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084A2900X | NCC00372-08 | NJ | N |   |   |   |   | 2084A2900X | NCC00372-08 | PA | N |   |   |   |   | 2084V0102X | 25MA07658800 | NJ | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084N0400X | MD432784 | PA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | C1-0012292 | DE | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 0018727880005 | 05 | PA |   | MEDICAID | 2095572 | 05 | NJ |   | MEDICAID |