Individual
USAMA M MOUSTAFA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1509 STATE ST, LA PORTE, IN 46350-3115
(219) 324-3431
(219) 362-3802
Mailing address
PO BOX 1690, LA PORTE, IN 46352-1690
(219) 326-2312
(219) 326-2584
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
01064003A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000542445
ANTHEM, BLUE CROSS BLUE SHIELD
IN
05
—
200877280
—
IN
Enumeration date
10/31/2007
Last updated
09/16/2020
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