Provider Demographics
NPI:1962060921
Name:AYYAT, MUMEN (MD)
Entity type:Individual
Prefix:
First Name:MUMEN
Middle Name:
Last Name:AYYAT
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 1:856 WEST NELSON STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:773-975-1600
Mailing Address - Fax:
Practice Address - Street 1:420 HOPKINSVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1102
Practice Address - Country:US
Practice Address - Phone:270-377-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2024-06-03
Deactivation Date:2020-01-17
Deactivation Code:
Reactivation Date:2020-01-27
Provider Licenses
StateLicense IDTaxonomies
KY59097208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program