Provider Demographics
NPI:1093978165
Name:MOHAMMED, ANSERUDDIN (MD)
Entity Type:Individual
Prefix:
First Name:ANSERUDDIN
Middle Name:
Last Name:MOHAMMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8300
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:119 WALNUT ST
Practice Address - Street 2:WALNUT PLAZA
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1625
Practice Address - Country:US
Practice Address - Phone:814-534-1095
Practice Address - Fax:814-534-6145
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361657792084P0800X, 2084P0804X
MI43010939352084P0800X, 2084P0804X
PAMD4418082084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026258280001Medicaid
PA221349Medicare PIN