Provider Demographics
NPI:1629592639
Name:MIMA, MAHMOUD
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:MIMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5906 N KENMORE AVE APT B-7
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-5109
Mailing Address - Country:US
Mailing Address - Phone:847-373-3359
Mailing Address - Fax:
Practice Address - Street 1:820 S WOOD ST
Practice Address - Street 2:CSN 515
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:847-373-3359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.069853208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology