Provider Demographics
NPI:1073681524
Name:MONTASIR, ESSAM A (MD)
Entity Type:Individual
Prefix:
First Name:ESSAM
Middle Name:A
Last Name:MONTASIR
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 1:236 SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-4666
Mailing Address - Country:US
Mailing Address - Phone:574-293-0052
Mailing Address - Fax:574-293-1739
Practice Address - Street 1:236 SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-4666
Practice Address - Country:US
Practice Address - Phone:574-293-0052
Practice Address - Fax:574-293-1739
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI063440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI308046210Medicaid
MM063440OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262220OtherBLUE CROSS-BLUE CROSS
MM063440OtherCHAMPUS-CHAMPUS
700H262220OtherBLUE CROSS-BLUE CROSS
F98587Medicare UPIN