Provider Demographics
NPI:1477828937
Name:ODESSA REPRODUCTIVE MEDICINE CENTER
Entity Type:Organization
Organization Name:ODESSA REPRODUCTIVE MEDICINE CENTER
Other - Org Name:MITWALLY FERTILITY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:MITWALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, HCLD, FACOG
Authorized Official - Phone:248-701-4157
Mailing Address - Street 1:122 CANDELARIA
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4711
Mailing Address - Country:US
Mailing Address - Phone:248-701-4157
Mailing Address - Fax:432-218-8804
Practice Address - Street 1:420 E 6TH ST STE 203
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4572
Practice Address - Country:US
Practice Address - Phone:432-580-4500
Practice Address - Fax:432-218-8804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0765207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty