Provider Demographics
NPI:1104881101
Name:AMIN, MOHAMMAD BASIL (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:BASIL
Last Name:AMIN
Suffix:
Gender:
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 2468
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177
Mailing Address - Country:US
Mailing Address - Phone:386-325-8482
Mailing Address - Fax:386-325-3512
Practice Address - Street 1:205 ZEAGLER DR.
Practice Address - Street 2:SUITE # 401-B
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177
Practice Address - Country:US
Practice Address - Phone:386-325-8482
Practice Address - Fax:386-325-3512
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072588207RA0401X
VT042.0014077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261232100Medicaid
FL261232100Medicaid
58837Medicare ID - Type Unspecified