Provider Demographics
NPI:1598210064
Name:MOHAMMAD, BUDOUR
Entity Type:Individual
Prefix:
First Name:BUDOUR
Middle Name:
Last Name:MOHAMMAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 W OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4330
Mailing Address - Country:US
Mailing Address - Phone:414-649-6000
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-649-6000
Practice Address - Fax:919-873-9821
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
WI118-017367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant