Provider Demographics
NPI:1730594060
Name:EL-TAYASH, MAHMOD FATHI (MD)
Entity type:Individual
Prefix:
First Name:MAHMOD
Middle Name:FATHI
Last Name:EL-TAYASH
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 1:122 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1829
Mailing Address - Country:US
Mailing Address - Phone:641-236-4323
Mailing Address - Fax:641-236-3411
Practice Address - Street 1:122 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1829
Practice Address - Country:US
Practice Address - Phone:641-236-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0089645174400000X
IAMD-48955208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist