Provider Demographics
NPI:1245206903
Name:EL-GAZZAR, MOURAD (MD)
Entity Type:Individual
Prefix:
First Name:MOURAD
Middle Name:
Last Name:EL-GAZZAR
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 1:20525 CENTER RIDGE RD
Mailing Address - Street 2:STE 220
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:440-333-2935
Practice Address - Street 1:15000 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107
Practice Address - Country:US
Practice Address - Phone:216-227-9964
Practice Address - Fax:216-221-5473
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057954E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
108122OtherKAISER
OHD368301OtherDIAGNOSTIC MEDICARE GROUP
OH3610861OtherASC MEDICARE GROUP
10826651OtherCAQH
341783789089OtherCARESOURCE
OH5676539OtherAETNA
CA4511OtherGROUP RR MEDICARE
OH110203792OtherRAILROAD MEDICARE
000000190833OtherANTHEM
OH0947560Medicaid
OH9273172OtherMEDICARE GROUP
OH108122OtherKAISER
1780634279OtherGROUP NPI
L57954OtherSUMMACARE APEX
9273172OtherGROUP MEDICAID
34-1783789OtherGROUP TIN
OH0947560Medicaid
OH4034593Medicare PIN