Provider Demographics
NPI:1346770781
Name:ELJACK, AMMAR FADLALLA (MD)
Entity Type:Individual
Prefix:
First Name:AMMAR
Middle Name:FADLALLA
Last Name:ELJACK
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 1:800 STANTON L YOUNG BLVD # 5340
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5018
Mailing Address - Country:US
Mailing Address - Phone:405-271-4742
Mailing Address - Fax:
Practice Address - Street 1:800 STANTON L YOUNG BLVD # 5340
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5018
Practice Address - Country:US
Practice Address - Phone:405-271-4742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301112401207R00000X
TXBP10070346207RC0000X
OK41229207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease