Provider Demographics
NPI:1154163277
Name:AMMAR, MAHMOUD (OD)
Entity type:Individual
Prefix:DR
First Name:MAHMOUD
Middle Name:
Last Name:AMMAR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 NEWPORT CREASENT
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ON
Mailing Address - Zip Code:N9E 4Z6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 RIVER PL
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-6028
Practice Address - Country:US
Practice Address - Phone:708-474-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011925152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program