Provider Demographics
NPI:1932108412
Name:ALLAM, MEDHAT (MD)
Entity Type:Individual
Prefix:MR
First Name:MEDHAT
Middle Name:
Last Name:ALLAM
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 1:365 COUNTY ROAD 39A
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5284
Mailing Address - Country:US
Mailing Address - Phone:631-287-6202
Mailing Address - Fax:
Practice Address - Street 1:365 COUNTY ROAD 39A
Practice Address - Street 2:SUITE 11
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5284
Practice Address - Country:US
Practice Address - Phone:631-287-6202
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193888208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY193888OtherLICENSE #
NY01649430Medicaid
NYG24898Medicare UPIN
NY01649430Medicaid