Provider Demographics
NPI:1235515727
Name:COMMONS DRIVE FAMILY MEDICINE
Entity Type:Organization
Organization Name:COMMONS DRIVE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KALOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-552-7412
Mailing Address - Street 1:4012 COMMONS DR W STE 112
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-8424
Mailing Address - Country:US
Mailing Address - Phone:304-552-7412
Mailing Address - Fax:
Practice Address - Street 1:4012 COMMONS DR W STE 112
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8424
Practice Address - Country:US
Practice Address - Phone:304-552-7412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty