Provider Demographics
NPI:1972391431
Name:MOHAMED, SAMSAM
Entity type:Individual
Prefix:
First Name:SAMSAM
Middle Name:
Last Name:MOHAMED
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 LITCHFIELD AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3352
Mailing Address - Country:US
Mailing Address - Phone:320-894-4265
Mailing Address - Fax:
Practice Address - Street 1:313 LITCHFIELD AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3352
Practice Address - Country:US
Practice Address - Phone:320-894-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNJ070155118207172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver