Provider Demographics
NPI:1447638689
Name:ALSANJALAWI, MUTAZ HAMDI SAID (MD)
Entity type:Individual
Prefix:
First Name:MUTAZ
Middle Name:HAMDI SAID
Last Name:ALSANJALAWI
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:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:937-641-6129
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1873
Practice Address - Country:US
Practice Address - Phone:937-641-4000
Practice Address - Fax:937-641-4500
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35127952208000000X
FLME1499342080P0204X
OH35.1279522080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116560900Medicaid
OH0175625Medicaid