Provider Demographics
NPI:1265507149
Name:MIJALLI, MAMDOUH N (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMDOUH
Middle Name:N
Last Name:MIJALLI
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-841-3846
Mailing Address - Fax:843-841-3848
Practice Address - Street 1:705 N 8TH AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2549
Practice Address - Country:US
Practice Address - Phone:843-841-3846
Practice Address - Fax:843-841-3848
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-23
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29714208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC297146Medicaid