Provider Demographics
NPI:1164005526
Name:AL-MUTAWALLI, WISAM (MD)
Entity type:Individual
Prefix:
First Name:WISAM
Middle Name:
Last Name:AL-MUTAWALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 TOWNSHIP BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031
Mailing Address - Country:US
Mailing Address - Phone:315-551-6000
Mailing Address - Fax:
Practice Address - Street 1:208 TOWNSHIP BLVD
Practice Address - Street 2:STE 100
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031
Practice Address - Country:US
Practice Address - Phone:315-551-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine