Healthcare Provider Details

I. General information

NPI: 1255951745
Provider Name (Legal Business Name): FARIS MOH'D MAHDI ALHAJ SA KAMAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DATES DR
ITHACA NY
14850-1345
US

IV. Provider business mailing address

201 DATES DR
ITHACA NY
14850-1345
US

V. Phone/Fax

Practice location:
  • Phone: 607-339-0630
  • Fax:
Mailing address:
  • Phone: 607-274-4011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number334493
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: