Provider Demographics
NPI:1467935858
Name:MAHDI, AHMED MOHAMED (NP)
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:MOHAMED
Last Name:MAHDI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 WILSHIRE BLVD APT 317
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2645
Mailing Address - Country:US
Mailing Address - Phone:256-348-5521
Mailing Address - Fax:
Practice Address - Street 1:12730 HEACOCK ST STE 4A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3040
Practice Address - Country:US
Practice Address - Phone:951-243-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2023-03-07
Deactivation Date:2018-09-12
Deactivation Code:
Reactivation Date:2018-09-19
Provider Licenses
StateLicense IDTaxonomies
CA95009179363LA2100X, 363LG0600X, 363LX0106X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95009179OtherCALIFORNIA STATE NURSE PRACTITIONER
CAMM4969448OtherDEA