Provider Demographics
NPI:1487245205
Name:MOHAMUD, MOHAMED
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:MOHAMUD
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 1:1567 SHERBURNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2327
Mailing Address - Country:US
Mailing Address - Phone:612-800-2776
Mailing Address - Fax:
Practice Address - Street 1:1567 SHERBURNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2327
Practice Address - Country:US
Practice Address - Phone:612-800-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1207445600025251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health