Provider Demographics
NPI:1326089194
Name:FAM, MOURAD S (MD)
Entity Type:Individual
Prefix:
First Name:MOURAD
Middle Name:S
Last Name:FAM
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 1:1 BROOKDALE PLAZA
Mailing Address - Street 2:7L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212
Mailing Address - Country:US
Mailing Address - Phone:718-240-5353
Mailing Address - Fax:718-240-6896
Practice Address - Street 1:1 BROOKDALE PLAZA
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212
Practice Address - Country:US
Practice Address - Phone:718-240-5353
Practice Address - Fax:718-240-6896
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205653207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01749408Medicaid
NY65H882Medicare ID - Type Unspecified
NY01749408Medicaid