Provider Demographics
NPI:1013398338
Name:MOHEMD, EAZ ALDEAN
Entity Type:Individual
Prefix:
First Name:EAZ ALDEAN
Middle Name:
Last Name:MOHEMD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 CASTLE ST
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-5807
Mailing Address - Country:US
Mailing Address - Phone:469-544-7173
Mailing Address - Fax:
Practice Address - Street 1:4117 N STORY RD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-5904
Practice Address - Country:US
Practice Address - Phone:469-544-7173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343800000XMedicaid