Provider Demographics
NPI:1063720753
Name:MBODJ, MOHAMED
Entity type:Individual
Prefix:MR
First Name:MOHAMED
Middle Name:
Last Name:MBODJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 KOMURA CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-2232
Mailing Address - Country:US
Mailing Address - Phone:513-236-0534
Mailing Address - Fax:
Practice Address - Street 1:1288 KOMURA CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-2232
Practice Address - Country:US
Practice Address - Phone:513-236-0534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH128027 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH128027 IVOtherLICENSE PRACTICAL NURSE