Provider Demographics
NPI:1225655285
Name:ISSA, MOHAMED (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:
Last Name:ISSA
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 1:19229 MACK AVE STE 34
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2857
Mailing Address - Country:US
Mailing Address - Phone:313-647-3245
Mailing Address - Fax:313-647-3244
Practice Address - Street 1:19229 MACK AVE STE 34
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2857
Practice Address - Country:US
Practice Address - Phone:313-647-3245
Practice Address - Fax:313-647-3244
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2023-06-29
Deactivation Date:2022-01-17
Deactivation Code:
Reactivation Date:2022-02-01
Provider Licenses
StateLicense IDTaxonomies
MI4301508803207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine