Provider Demographics
NPI:1992290613
Name:GISMALLA, MOHAMED ELNAEM (MD)
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:ELNAEM
Last Name:GISMALLA
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 1:5061 VILLA LINDE PKWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3412
Mailing Address - Country:US
Mailing Address - Phone:810-733-6000
Mailing Address - Fax:810-733-0845
Practice Address - Street 1:5061 VILLA LINDE PKWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3412
Practice Address - Country:US
Practice Address - Phone:810-733-6000
Practice Address - Fax:810-733-0845
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2025-04-29
Deactivation Date:2024-09-10
Deactivation Code:
Reactivation Date:2024-09-26
Provider Licenses
StateLicense IDTaxonomies
MI4301502977207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine