Individual
MUSA MODAD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
719 S MAIN ST, MOSCOW, ID 83843-3041
(208) 883-1152
(208) 882-1486
Mailing address
700 S MAIN ST, MOSCOW, ID 83843-3046
(208) 882-4511
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
103780
MO
207R00000X
Internal Medicine Physician
103780
MO
207R00000X
Internal Medicine Physician
Primary
M-12814
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1235680703
NPI # FOR INTERNAL MEDICINE CLINIC
ID
05
—
1902917834
—
MO
05
—
206687410
—
MO
01
—
M-12814
IDAHO LICENSE
ID
01
—
P00430675
RAILROAD MEDICARE
—
Enumeration date
08/31/2006
Last updated
07/21/2022
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