Provider Demographics
NPI:1619160553
Name:EL NEMR, MOHAMED A (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:A
Last Name:EL NEMR
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 W HIGH ST STE 3
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1681
Practice Address - Country:US
Practice Address - Phone:419-636-4517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077490A207V00000X
OH35.092751207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN163460007OtherMEDICARE PTAN
OH9934723OtherGROUP PTAN
OH34-1689161OtherTAX ID FOR JTDM FAMILY PRACTICE, LLC
OH0105065OtherMEDICAID GROUP
OH2998645Medicaid
OH9934723OtherGROUP PTAN