Healthcare Provider Details

I. General information

NPI: 1659807972
Provider Name (Legal Business Name): MOHAMED AHMED SHAMA MD, MSC, MRCS, EBSQ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 TULANE AVE RM 8510-B
NEW ORLEANS LA
70112-2632
US

IV. Provider business mailing address

1430 TULANE AVE RM 8510-B
NEW ORLEANS LA
70112-2632
US

V. Phone/Fax

Practice location:
  • Phone: 409-978-6447
  • Fax: 504-754-7949
Mailing address:
  • Phone: 409-978-6447
  • Fax: 504-754-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number324894
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number324894
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: