Provider Demographics
NPI:1609856632
Name:MOHAMED-SANTA, ODETTE (MD)
Entity Type:Individual
Prefix:
First Name:ODETTE
Middle Name:
Last Name:MOHAMED-SANTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S. BOLIVAR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-4100
Mailing Address - Country:US
Mailing Address - Phone:903-935-9100
Mailing Address - Fax:903-935-9102
Practice Address - Street 1:402 S BOLIVAR ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-4110
Practice Address - Country:US
Practice Address - Phone:903-935-9100
Practice Address - Fax:903-935-9102
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3586OtherMEDICARE LEGACY
TX104469503Medicaid
E19671Medicare UPIN
TX104469503Medicaid