Provider Demographics
NPI:1497733075
Name:MAHMOOD, MUSHTAQ (MD)
Entity Type:Individual
Prefix:DR
First Name:MUSHTAQ
Middle Name:
Last Name:MAHMOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MUSHTAQ
Other - Middle Name:
Other - Last Name:MAHMOOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10325 DEWHURST RD
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-8403
Mailing Address - Country:US
Mailing Address - Phone:440-414-9260
Mailing Address - Fax:216-201-5581
Practice Address - Street 1:10325 DEWHURST RD
Practice Address - Street 2:OHIO MEDICAL GROUP
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-8403
Practice Address - Country:US
Practice Address - Phone:440-414-9260
Practice Address - Fax:216-201-5581
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.016032207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067078Medicaid
OHH106452Medicare PIN