Healthcare Provider Details

I. General information

NPI: 1588015143
Provider Name (Legal Business Name): MOHAMMAD ELDOMERY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 DANNY THOMAS PL
MEMPHIS TN
38105-3678
US

IV. Provider business mailing address

262 DANNY THOMAS PL # MS 515
MEMPHIS TN
38105-3678
US

V. Phone/Fax

Practice location:
  • Phone: 888-226-4343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11018989A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number63826
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number63826
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: