Provider Demographics
NPI:1992078547
Name:ISMAIL, MOHAMED LADAK (PTA)
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:LADAK
Last Name:ISMAIL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 6TH AVE
Mailing Address - Street 2:#2
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2540
Mailing Address - Country:US
Mailing Address - Phone:415-316-9701
Mailing Address - Fax:
Practice Address - Street 1:1201 6TH AVE
Practice Address - Street 2:#2
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-2540
Practice Address - Country:US
Practice Address - Phone:415-316-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAAT5509225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55213Medicare PIN