Provider Demographics
NPI:1841286788
Name:ATWA, HESHAM MAHMOUD (MD)
Entity type:Individual
Prefix:DR
First Name:HESHAM
Middle Name:MAHMOUD
Last Name:ATWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:620 BELLE TERRE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2500
Mailing Address - Country:US
Mailing Address - Phone:631-476-9296
Mailing Address - Fax:631-476-9298
Practice Address - Street 1:620 BELLE TERRE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2500
Practice Address - Country:US
Practice Address - Phone:631-476-9296
Practice Address - Fax:631-476-9298
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY221306208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02229490Medicaid
NYH37248Medicare UPIN
NY405I21Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER