Provider Demographics
NPI:1316204894
Name:ELBATTA, MOHAMMAD ADNAN
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:ADNAN
Last Name:ELBATTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17400 IRVINE BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3030
Mailing Address - Country:US
Mailing Address - Phone:714-937-9400
Mailing Address - Fax:714-937-9404
Practice Address - Street 1:17400 IRVINE BLVD STE F
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:714-937-9400
Practice Address - Fax:714-937-9404
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA162124207R00000X
390200000X
OH35133929207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0299053Medicaid
OH3025372Medicaid