Provider Demographics
NPI:1427088715
Name:ROSTOM, MOURAD L (MD)
Entity type:Individual
Prefix:
First Name:MOURAD
Middle Name:L
Last Name:ROSTOM
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 1:310 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-2705
Mailing Address - Country:US
Mailing Address - Phone:330-675-4450
Mailing Address - Fax:330-675-4451
Practice Address - Street 1:310 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-2705
Practice Address - Country:US
Practice Address - Phone:330-675-4450
Practice Address - Fax:330-675-4451
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061163207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH400887OtherUNITED HEALTHCARE
OH0855552Medicaid
OH78911OtherHEALTH ASSURANCE
OHQ025272OtherHOMETOWN
OH000000243198OtherANTHEM BC/BS
OHJ61163OtherSUMMACARE
OH110247872OtherRAILROAD MEDICARE
OH000720761OtherHIGHMARK BC/BS PA
OH341341025028OtherCARESOURCE
OH400887OtherUNITED HEALTHCARE
OHJ61163OtherSUMMACARE
OH341341025028OtherCARESOURCE