Healthcare Provider Details

I. General information

NPI: 1124681051
Provider Name (Legal Business Name): TALAL AMMIN AL-MOHAMAD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4209 GATEWAY BLVD
NEWBURGH IN
47630-8900
US

IV. Provider business mailing address

PO BOX 689
ALLENTOWN PA
18105-1556
US

V. Phone/Fax

Practice location:
  • Phone: 812-842-0907
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberOT021434
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number02009217A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: