MEDICARE: MORTADA ALTWAIJ OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901005695	MI

General Provider Information

NPI Number	:	1700562758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MORTADA ALTWAIJ OD

Provider Business Mailing Address
First Line	:	1701 SOUTH BLVD E STE 180
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-6115
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 SOUTH BLVD E STE 180
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-6115
Country	:	US
Telephone Number	:	586-203-3575
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2023
Last Update Date	:	03/14/2025

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