Provider Demographics
NPI:1467171462
Name:AL MADADHA, MOHAMMAD E (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:E
Last Name:AL MADADHA
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 1:1139 E WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-3763
Mailing Address - Country:US
Mailing Address - Phone:727-241-3524
Mailing Address - Fax:
Practice Address - Street 1:2340 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5371
Practice Address - Country:US
Practice Address - Phone:727-241-3524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246QL0900X, 170100000X
MO2022026934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
No246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant