Provider Demographics
NPI:1518913003
Name:AJJAN, MOHAMMED
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:AJJAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MOHAMMED
Other - Middle Name:
Other - Last Name:AJJAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:840 PINE ST STE 880
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7525
Mailing Address - Country:US
Mailing Address - Phone:478-743-7092
Mailing Address - Fax:478-743-6293
Practice Address - Street 1:840 PINE ST
Practice Address - Street 2:SUITE 880
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2100
Practice Address - Country:US
Practice Address - Phone:478-743-7092
Practice Address - Fax:478-743-6293
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051773174400000X
GA51773207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00960858AMedicaid
GA00960858AMedicaid
GA00960858AMedicaid