Healthcare Provider Details

I. General information

NPI: 1861485740
Provider Name (Legal Business Name): HAITHAM M ELSAMALOTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 PARK CENTER CT.
TOLEDO OH
43615
US

IV. Provider business mailing address

5757 PARK CENTER CT.
TOLEDO OH
43615
US

V. Phone/Fax

Practice location:
  • Phone: 419-474-4064
  • Fax: 419-472-2772
Mailing address:
  • Phone: 419-474-4064
  • Fax: 419-472-2772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number35072581
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35072581
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: