Provider Demographics
NPI:1538451992
Name:FADLALLA, MOHAMMED (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:FADLALLA
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:PO BOX 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5504
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN STREET
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-584-4503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35126843207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH384120Medicare PIN