Provider Demographics
NPI:1700820487
Name:ABDULLA, MOHAMED A (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:A
Last Name:ABDULLA
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:PO BOX 1476
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0476
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2634
Practice Address - Country:US
Practice Address - Phone:570-552-1435
Practice Address - Fax:570-552-1510
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047282L207ZC0500X, 207ZP0102X
NJ25MA07827100207ZP0101X
NY232717-1291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0060275Medicaid
NJ0060275Medicaid
NJG17258Medicare UPIN