Provider Demographics
NPI:1700302163
Name:ELGAMAL, MOHAMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:ELGAMAL
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-676-4444
Practice Address - Fax:812-676-4445
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2023-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301113553207R00000X
IN01089523A207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN090540867OtherMEDICARE PTAN
INQ00539106OtherRAILROAD PTAN