Provider Demographics
NPI:1982674602
Name:MIDAMBA, FATUMA (MD)
Entity Type:Individual
Prefix:DR
First Name:FATUMA
Middle Name:
Last Name:MIDAMBA
Suffix:
Gender:F
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 24160
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-0160
Mailing Address - Country:US
Mailing Address - Phone:216-233-2527
Mailing Address - Fax:216-591-0943
Practice Address - Street 1:3619 PARK EAST DR
Practice Address - Street 2:205 S.
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4330
Practice Address - Country:US
Practice Address - Phone:216-591-0942
Practice Address - Fax:440-591-0943
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBM5763986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0860278OtherMEDICARE
OH2073572Medicaid
OHG92217Medicare UPIN