Provider Demographics
NPI:1720475585
Name:BEN MOHA, RAYNA (MD)
Entity type:Individual
Prefix:
First Name:RAYNA
Middle Name:
Last Name:BEN MOHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3134 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3134 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4414
Practice Address - Country:US
Practice Address - Phone:312-766-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125080199207R00000X, 207R00000X
WAAP60677447363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1720475585Medicaid
WAP01744079OtherRR MEDICARE WVH
WAG8959165, G8959166Medicare PIN