Provider Demographics
NPI:1013257575
Name:AL-SAMARRAIE, MOHANNAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHANNAD
Middle Name:
Last Name:AL-SAMARRAIE
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 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-882-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:3215 WINGATE CT
Practice Address - Street 2:SUITE 102
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7214
Practice Address - Country:US
Practice Address - Phone:573-882-8920
Practice Address - Fax:573-884-4868
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017029105207W00000X
MIL2316364207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology