Provider Demographics
NPI:1174559876
Name:EL-SAMAD, AHMAD KASSEM (DPM)
Entity type:Individual
Prefix:DR
First Name:AHMAD
Middle Name:KASSEM
Last Name:EL-SAMAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9120 DOUBLETREE DR S
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7655
Mailing Address - Country:US
Mailing Address - Phone:219-736-1010
Mailing Address - Fax:219-736-1090
Practice Address - Street 1:9239 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7046
Practice Address - Country:US
Practice Address - Phone:219-736-1010
Practice Address - Fax:219-736-1090
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001024A213E00000X, 213EP0504X, 213EP1101X, 213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN07001024AOtherMEDICAL LICENSE
IN07001024BOtherINDIANA CSR
IN6157100001OtherDMERC
IL016-005273OtherMEDICAL LICENSE
IN200-824830Medicaid
IN6157100001OtherDMERC
IN200-824830Medicaid