Provider Demographics
NPI:1275195703
Name:AL JAMMAL, MUSTAFA (MBBCH)
Entity Type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:
Last Name:AL JAMMAL
Suffix:
Gender:M
Credentials:MBBCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1900
Mailing Address - Country:US
Mailing Address - Phone:216-526-3126
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-1000
Practice Address - Fax:216-844-8216
Is Sole Proprietor?:No
Enumeration Date:2019-07-04
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA88125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program