Provider Demographics
NPI:1720696826
Name:MATAR, FATH ELRAHMAN MOHAMED SR
Entity Type:Individual
Prefix:MR
First Name:FATH ELRAHMAN
Middle Name:MOHAMED
Last Name:MATAR
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 PLEASANT MEADOW BLVD APT 11
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-4969
Mailing Address - Country:US
Mailing Address - Phone:718-971-0270
Mailing Address - Fax:
Practice Address - Street 1:282 PLEASANT MEADOW BLVD APT 11
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-4969
Practice Address - Country:US
Practice Address - Phone:718-971-0270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHVD527562172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver