Provider Demographics
NPI:1437159548
Name:MOHAMMAD, WALI (MD)
Entity Type:Individual
Prefix:
First Name:WALI
Middle Name:
Last Name:MOHAMMAD
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 1:2880 BAISLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-6117
Mailing Address - Country:US
Mailing Address - Phone:718-918-9158
Mailing Address - Fax:718-822-3990
Practice Address - Street 1:2880 BAISLEY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-6117
Practice Address - Country:US
Practice Address - Phone:718-918-9158
Practice Address - Fax:718-822-3990
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1353442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00390565Medicaid
03A691Medicare ID - Type Unspecified
NY00390565Medicaid