Healthcare Provider Details

I. General information

NPI: 1053970640
Provider Name (Legal Business Name): MAHMOUD GOUDA ABDELRAHMAN ABDELSALAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 FANNIN ST STE 1801
HOUSTON TX
77030-2744
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE STE 101
CHARLESTON WV
25304-1215
US

V. Phone/Fax

Practice location:
  • Phone: 346-238-0115
  • Fax:
Mailing address:
  • Phone: 304-388-8200
  • Fax: 304-388-7087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: