Provider Demographics
NPI:1003518259
Name:MOUTCHOU, MOHAMMED (LSA)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:MOUTCHOU
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 CHABLIS CIR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1947
Mailing Address - Country:US
Mailing Address - Phone:434-284-0346
Mailing Address - Fax:
Practice Address - Street 1:2837 CHABLIS CIR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-1947
Practice Address - Country:US
Practice Address - Phone:434-284-0346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000723246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant