Provider Demographics
NPI:1770788036
Name:MORTADA, MOHAMMAD EYMAN (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:EYMAN
Last Name:MORTADA
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 2040
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-2040
Mailing Address - Country:US
Mailing Address - Phone:414-649-3390
Mailing Address - Fax:414-649-5769
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 777
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-649-3390
Practice Address - Fax:414-649-5769
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43167-020207R00000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34173300Medicaid
003854475Medicare UPIN
003860350Medicare PIN
004004130Medicare PIN
WI21309400Medicaid
003840245Medicare PIN