Basic Information
Provider Information | |||||||||
NPI: | 1184867996 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OMBALLI | ||||||||
FirstName: | MOHAMED | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4510 DORR ST | ||||||||
Address2: | # MS840 | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436154040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193835334 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1325 CONFERENCE DR | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436148009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193836644 | ||||||||
FaxNumber: | 4193832924 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2009 | ||||||||
LastUpdateDate: | 03/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD.205534 | LA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0200X | ME139906 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | ME139906 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 55410 | WI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | Q9220 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208M00000X | MD.205534 | LA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207RP1001X | 35.140884 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 0433282 | 05 | OH |   | MEDICAID | 1184867996 | 05 | WI |   | MEDICAID |