Healthcare Provider Details

I. General information

NPI: 1992266092
Provider Name (Legal Business Name): MOHAMAD BELAL ALDAAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 06/06/2022
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S JACKSON ST
LOUISVILLE KY
40202-1675
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-1603
  • Fax: 502-852-1961
Mailing address:
  • Phone: 502-561-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4351045455
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number55652
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: