Provider Demographics
NPI:1609826668
Name:MEMON, MOHAMMED A (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:A
Last Name:MEMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 SILAS DEANE HWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-2124
Mailing Address - Country:US
Mailing Address - Phone:860-436-9880
Mailing Address - Fax:860-436-9850
Practice Address - Street 1:415 SILAS DEANE HWY
Practice Address - Street 2:SUITE #210
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2124
Practice Address - Country:US
Practice Address - Phone:860-436-9880
Practice Address - Fax:860-436-9850
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042588207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P3623891OtherOXFORD
CT001425885Medicaid
042588OtherCONNECTICARE
3722953OtherAETNA
4637105OtherCIGNA
36663OtherHEALTH NEW ENGLAND
010042588CT01OtherANTHEM BLUE CROSS
CT00142588500OtherBLUE CARE FAMILY PLAN
2V7183OtherHEALTH NET
I16334Medicare UPIN
P3623891OtherOXFORD
010042588CT01OtherANTHEM BLUE CROSS
080001697Medicare PIN