Healthcare Provider Details

I. General information

NPI: 1649650995
Provider Name (Legal Business Name): MOHAMMAD ALI ABDEL JAWAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date: 01/19/2016
Reactivation Date: 03/15/2016

III. Provider practice location address

929 N SAINT FRANCIS AVE
WICHITA KS
67214-3821
US

IV. Provider business mailing address

6516 W PALMETTO ST
WICHITA KS
67205-5100
US

V. Phone/Fax

Practice location:
  • Phone: 316-268-5000
  • Fax:
Mailing address:
  • Phone: 505-900-7814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-40568
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number04-40568
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: