Provider Demographics
NPI:1487003760
Name:MOHAMED, IDIL AHMED
Entity type:Individual
Prefix:MS
First Name:IDIL
Middle Name:AHMED
Last Name:MOHAMED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 DUNLAP ST N
Mailing Address - Street 2:STE 400M
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4200
Mailing Address - Country:US
Mailing Address - Phone:612-203-3638
Mailing Address - Fax:651-348-8158
Practice Address - Street 1:393 DUNLAP ST N
Practice Address - Street 2:STE 400M
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4200
Practice Address - Country:US
Practice Address - Phone:612-203-3638
Practice Address - Fax:651-348-8158
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN372823251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health