Provider Demographics
NPI:1346413929
Name:EHTESHAM, MONEEB M (MD)
Entity Type:Individual
Prefix:DR
First Name:MONEEB
Middle Name:M
Last Name:EHTESHAM
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 1:201 GOVERNORS DR SW FL 1
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-5171
Mailing Address - Country:US
Mailing Address - Phone:256-533-1600
Mailing Address - Fax:256-539-0856
Practice Address - Street 1:201 GOVERNORS DR SW FL 1
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5171
Practice Address - Country:US
Practice Address - Phone:256-533-1600
Practice Address - Fax:256-539-0856
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUMC-129207T00000X
AL42923207T00000X
MO2014029655207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL272208Medicaid
ALA13430AOtherMEDICARE
MO132680695Medicare PIN
OK200598350AMedicaid