Provider Demographics
NPI:1558660407
Name:AFFANEH, MOHAMED
Entity Type:Individual
Prefix:MR
First Name:MOHAMED
Middle Name:
Last Name:AFFANEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 LACOMA DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3200
Mailing Address - Country:US
Mailing Address - Phone:708-415-8875
Mailing Address - Fax:773-488-1523
Practice Address - Street 1:1254 LACOMA DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3200
Practice Address - Country:US
Practice Address - Phone:708-415-8875
Practice Address - Fax:773-488-1523
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA15054080159172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver