Provider Demographics
NPI:1760418628
Name:ELMALAH, AMIN (MD)
Entity Type:Individual
Prefix:
First Name:AMIN
Middle Name:
Last Name:ELMALAH
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 4966
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-4966
Mailing Address - Country:US
Mailing Address - Phone:318-388-6050
Mailing Address - Fax:318-998-3017
Practice Address - Street 1:2503 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2987
Practice Address - Country:US
Practice Address - Phone:318-388-6050
Practice Address - Fax:318-388-3204
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12568R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1437719Medicaid
LAP00259854OtherRAILROAD MEDICARE
LAP00259854OtherRAILROAD MEDICARE
LA5H428Medicare PIN
LAG32858Medicare UPIN