Healthcare Provider Details

I. General information

NPI: 1306848577
Provider Name (Legal Business Name): ABDUL KAWAMLEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6375 US HIGHWAY 6 STE B
PORTAGE IN
46368-5218
US

IV. Provider business mailing address

6375 US HIGHWAY 6 STE B
PORTAGE IN
46368-5218
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-0400
  • Fax: 219-762-2460
Mailing address:
  • Phone: 219-762-0400
  • Fax: 219-762-2460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number10152395A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: