Provider Demographics
NPI:1306805304
Name:MAMLOUK, MOHAMED BASHAR (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:BASHAR
Last Name:MAMLOUK
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 1:30701 LORAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-6325
Mailing Address - Country:US
Mailing Address - Phone:440-274-5035
Mailing Address - Fax:440-716-8608
Practice Address - Street 1:20455 LORAIN RD STE 104B
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3529
Practice Address - Country:US
Practice Address - Phone:440-356-2715
Practice Address - Fax:440-356-6978
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-038540207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0366698Medicaid
OH264168OtherFEDERAL BLACK LUNG
OH000000130207OtherANTHEM
OH2597481OtherUNITED HEALTHCARE
OH341313510BMOtherSUMMACARE
OH18958OtherQUALCHOICE
OH4007588OtherAETNA
OHA77891Medicare UPIN
OH0366698Medicaid
OHA77891Medicare UPIN