Provider Demographics
NPI:1457350688
Name:ELTAJI, AMAL M (MD)
Entity Type:Individual
Prefix:DR
First Name:AMAL
Middle Name:M
Last Name:ELTAJI
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 1:3401 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2490
Mailing Address - Country:US
Mailing Address - Phone:419-385-6457
Mailing Address - Fax:419-385-2555
Practice Address - Street 1:3401 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2418
Practice Address - Country:US
Practice Address - Phone:419-385-6457
Practice Address - Fax:419-385-2555
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-042956174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0431769Medicaid
OH0431769Medicaid
OHCO2233Medicare UPIN