Provider Demographics
NPI:1891762126
Name:MIKDASHI, JAMAL A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMAL
Middle Name:A
Last Name:MIKDASHI
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 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-706-6474
Mailing Address - Fax:410-706-0231
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-706-6474
Practice Address - Fax:410-706-0231
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD38046207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD525809-02OtherBLUE CROSS/BLUE SHIELD
DC037523500Medicaid
DE1891762126Medicaid
MD759111000Medicaid
MD473MMedicare PIN
MD759111000Medicaid
DC037523500Medicaid