Provider Demographics
NPI:1467519751
Name:EL ASSAL MAXIMOUS, MERVET (MD)
Entity Type:Individual
Prefix:
First Name:MERVET
Middle Name:
Last Name:EL ASSAL MAXIMOUS
Suffix:
Gender:F
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:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:BRACEY
Mailing Address - State:VA
Mailing Address - Zip Code:23919-0456
Mailing Address - Country:US
Mailing Address - Phone:434-774-2500
Mailing Address - Fax:434-447-4704
Practice Address - Street 1:416 DURANT ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1614
Practice Address - Country:US
Practice Address - Phone:434-774-2500
Practice Address - Fax:434-447-4704
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053050208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAI16894Medicare UPIN