Provider Demographics
NPI:1194719286
Name:MAHMOUD, SHABAN (MD)
Entity type:Individual
Prefix:
First Name:SHABAN
Middle Name:
Last Name:MAHMOUD
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 1:1330 COSHOCTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-1440
Mailing Address - Country:US
Mailing Address - Phone:740-393-9000
Mailing Address - Fax:
Practice Address - Street 1:1330 COSHOCTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1440
Practice Address - Country:US
Practice Address - Phone:740-393-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH74977207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2083632Medicaid
000000207469OtherANTHEM
G80998Medicare UPIN
000000207469OtherANTHEM