Basic Information
| Provider Information | |||||||||
| NPI: | 1881800332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAMO | ||||||||
| FirstName: | ELIAS | ||||||||
| MiddleName: | KASSA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13339 MOONLIGHT TRAIL DR | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209066700 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11890 HEALING WAY | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209047917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406374000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0064866 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD035593 | DC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.