Healthcare Provider Details

I. General information

NPI: 1255590915
Provider Name (Legal Business Name): MOHANED ADIL AL-HUMADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MAIN ST
OLEAN NY
14760-1513
US

IV. Provider business mailing address

908 NIAGARA FALLS BLVD STE 208
NORTH TONAWANDA NY
14120-2019
US

V. Phone/Fax

Practice location:
  • Phone: 716-701-1510
  • Fax: 716-701-1517
Mailing address:
  • Phone: 716-692-3302
  • Fax: 716-692-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number257934
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: