Basic Information
| Provider Information | |||||||||
| NPI: | 1215999057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NACHABE | ||||||||
| FirstName: | MOUSTAFA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855852 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Practice Location | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855852 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 08/13/2009 | ||||||||
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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 | 208000000X | MD10655R | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1452904 | 05 | LA | MEDICAID | 1925349 | 05 | LA | MEDICAID | 1444642 | 05 | LA | MEDICAID | 1990078 | 05 | LA | MEDICAID | 1579483 | 05 | LA | MEDICAID |