Provider Demographics
NPI:1700104056
Name:ABOUSAMRA, MAMDOU (DPM)
Entity Type:Individual
Prefix:
First Name:MAMDOU
Middle Name:
Last Name:ABOUSAMRA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 30TH DR STE 1L
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2701
Mailing Address - Country:US
Mailing Address - Phone:646-421-9356
Mailing Address - Fax:
Practice Address - Street 1:2519 30TH DR STE 1L
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2701
Practice Address - Country:US
Practice Address - Phone:646-421-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006502213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery