Provider Demographics
NPI: | 1306828421 |
---|---|
Name: | MOUKAMAL, EZZ ELDIN (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | EZZ ELDIN |
Middle Name: | |
Last Name: | MOUKAMAL |
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: | 3824 NORTHERN PIKE |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | MONROEVILLE |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 15146 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 412-457-0060 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2570 HAYMAKER RD |
Practice Address - Street 2: | |
Practice Address - City: | MONROEVILLE |
Practice Address - State: | PA |
Practice Address - Zip Code: | 15146-3513 |
Practice Address - Country: | US |
Practice Address - Phone: | 412-858-7618 |
Practice Address - Fax: | 412-858-7628 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-15 |
Last Update Date: | 2020-11-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | MD417539 | 208M00000X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 0019122840004 | Medicaid | |
PA | 01912284 | Medicaid | |
PA | H65596 | Medicare UPIN | |
PA | 01912284 | Medicaid | |
H65596 | Medicare UPIN |