Healthcare Provider Details

I. General information

NPI: 1700104056
Provider Name (Legal Business Name): MAMDOU ABOUSAMRA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 30TH DR STE 1L
ASTORIA NY
11102-2701
US

IV. Provider business mailing address

2519 30TH DR STE 1L
ASTORIA NY
11102-2701
US

V. Phone/Fax

Practice location:
  • Phone: 646-421-9356
  • Fax:
Mailing address:
  • Phone: 646-421-9356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberN006502
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: