Provider Demographics
NPI:1528551058
Name:AL-OTAIBI, MOHAMAD NIDAL
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:NIDAL
Last Name:AL-OTAIBI
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 1:17 CHAMARD WAY UNIT 17
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-3860
Mailing Address - Country:US
Mailing Address - Phone:507-339-1140
Mailing Address - Fax:
Practice Address - Street 1:9 HEALTHCARE DR STE 105
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9445
Practice Address - Country:US
Practice Address - Phone:207-282-3666
Practice Address - Fax:207-294-3552
Is Sole Proprietor?:No
Enumeration Date:2018-06-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT215733207R00000X
MEMD27596207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine