Provider Demographics
NPI:1992476857
Name:ALI-MOHAMED, KHADRA S (DO)
Entity type:Individual
Prefix:
First Name:KHADRA
Middle Name:S
Last Name:ALI-MOHAMED
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10347 CROSS CREEK BLVD STE C4
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2993
Mailing Address - Country:US
Mailing Address - Phone:813-421-1453
Mailing Address - Fax:
Practice Address - Street 1:10347 CROSS CREEK BLVD STE C4
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2993
Practice Address - Country:US
Practice Address - Phone:813-421-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7333156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician