Provider Demographics
NPI:1245220763
Name:ALMUDALLAL, RIAD S (MD)
Entity Type:Individual
Prefix:DR
First Name:RIAD
Middle Name:S
Last Name:ALMUDALLAL
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 1:1939 ROLAND CLARKE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1445
Mailing Address - Country:US
Mailing Address - Phone:703-435-3366
Mailing Address - Fax:703-782-8833
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 246
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6756
Practice Address - Country:US
Practice Address - Phone:301-665-4585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053410207RG0100X
VA0101058637207RG0100X
FLME106048207RG0100X
MDD93995207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0654433Medicare ID - Type Unspecified
A17735Medicare UPIN