Provider Demographics
NPI:1588716641
Name:MAMO, GEORGE J (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:J
Last Name:MAMO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 GRAND CENTRAL AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3407 WILKENS AVE STE 2010
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5072
Practice Address - Country:US
Practice Address - Phone:410-664-0929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0036523208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD192011100Medicaid
MD52581804OtherCAREFIRST OF MD PROV. NO.
MD1900383OtherAMERICHOICE PROV. NO.
MDE6120002OtherBCBS FEDERAL PROVIDER NO.
MD20679012OtherUNITED HEALTHCARE
MDE6120002OtherBLUE CHOICE PROV. NO.
MD614797OtherMAMSI PROVIDER NUMBER
MD192011100Medicaid
MD9290Medicare PIN
340006654Medicare PIN
MDF38663Medicare UPIN