Provider Demographics
NPI:1699719468
Name:JARRAH, MAMOON (MD)
Entity type:Individual
Prefix:
First Name:MAMOON
Middle Name:
Last Name:JARRAH
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 1:2525 HARBOR BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5317
Mailing Address - Country:US
Mailing Address - Phone:941-613-3773
Mailing Address - Fax:941-629-6770
Practice Address - Street 1:2525 HARBOR BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5317
Practice Address - Country:US
Practice Address - Phone:941-613-3773
Practice Address - Fax:941-629-6770
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00405652086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL770002062OtherRR MEDICARE
TN629729OtherBCBS TENNESSEE
FL066974100Medicaid
FL08118OtherCOMMERCIAL
FL4652614OtherAETNA
FL5744032-004OtherCIGNA
FL629729OtherANTHEM
FL629729OtherANTHEM
FL5744032-004OtherCIGNA