Healthcare Provider Details

I. General information

NPI: 1306805304
Provider Name (Legal Business Name): MOHAMED BASHAR MAMLOUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20455 LORAIN RD STE 104B
FAIRVIEW PARK OH
44126-3529
US

IV. Provider business mailing address

30701 LORAIN RD STE A
NORTH OLMSTED OH
44070-6325
US

V. Phone/Fax

Practice location:
  • Phone: 440-356-2715
  • Fax: 440-356-6978
Mailing address:
  • Phone: 440-274-5035
  • Fax: 440-716-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-038540
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: