Provider Demographics
NPI:1114194156
Name:FATTAL, MOHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:FATTAL
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 6716
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41022-6716
Mailing Address - Country:US
Mailing Address - Phone:859-342-4087
Mailing Address - Fax:
Practice Address - Street 1:3876 TURKEYFOOT RD
Practice Address - Street 2:
Practice Address - City:ELSMERE
Practice Address - State:KY
Practice Address - Zip Code:41018-2838
Practice Address - Country:US
Practice Address - Phone:859-342-8775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43438207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine