Provider Demographics
NPI:1205845468
Name:ASSAF, MOHAMMAD THEIB (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:THEIB
Last Name:ASSAF
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:PO BOX 1616
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38088-1616
Mailing Address - Country:US
Mailing Address - Phone:901-683-8448
Mailing Address - Fax:901-683-8558
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE # 722B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-683-8448
Practice Address - Fax:901-683-8558
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13794174400000X
TNMD0000027300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114404Medicaid
MS00114404Medicaid
TNF93491Medicare UPIN
MS130000106Medicare ID - Type Unspecified