Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 22493 | WV |
N | 207Q00000X | Family Doctor | 35.088590 | OH |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 22493 | WV |
NPI | 1619065190 |
---|---|
Provider Name | Dr. Mohamad Samah Kalou |
First Address | South Charleston, WV 25309-1474 |
Second Address | Charleston, WV 25304-2122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 26/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001902627 | BCBS (01) | WV |
3810006491 | (05) | WV |
I63345 | (02) | WV |