Basic Information
| Provider Information | |||||||||
| NPI: | 1972189520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELGAMAL | ||||||||
| FirstName: | MOHAMED | ||||||||
| MiddleName: | YASSIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 NEWHALL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065111909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033935445 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037098685 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2021 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 06-0646844 | CT | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.