Provider Demographics
NPI:1508968561
Name:EID, MAHMOUD (MD)
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:EID
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 1:12 DOTY AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4721
Mailing Address - Country:US
Mailing Address - Phone:718-524-6228
Mailing Address - Fax:
Practice Address - Street 1:406 15 TH STE M1A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-6054
Practice Address - Country:US
Practice Address - Phone:718-369-7560
Practice Address - Fax:718-269-7563
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA067775207P00000X
NY015911-1390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8777501Medicaid
NJH31954Medicare UPIN
NJ053952B8AMedicare PIN
P00413574Medicare PIN
NJ8777501Medicaid