Provider Demographics
NPI:1467138453
Name:DIAB, ELOSAMA A
Entity Type:Individual
Prefix:
First Name:ELOSAMA
Middle Name:A
Last Name:DIAB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6127 W WAGONER RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1150
Mailing Address - Country:US
Mailing Address - Phone:214-774-7006
Mailing Address - Fax:
Practice Address - Street 1:4030 W GRANDVIEW RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2731
Practice Address - Country:US
Practice Address - Phone:480-599-5917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)