Provider Demographics
NPI:1619078292
Name:MOHAMMAD, MOHAMMAD (DPM)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:MOHAMMAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:MOHAMMAD
Other - Middle Name:T
Other - Last Name:MOHAMMAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:3184 W BROAD ST
Mailing Address - Street 2:STE C
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1327
Mailing Address - Country:US
Mailing Address - Phone:614-274-7448
Mailing Address - Fax:614-274-4498
Practice Address - Street 1:3184 W BROAD ST
Practice Address - Street 2:STE C
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1327
Practice Address - Country:US
Practice Address - Phone:614-274-7448
Practice Address - Fax:614-274-4498
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003305M213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2375826Medicaid
OH4103241Medicare PIN
OHM04103242Medicare ID - Type Unspecified
OH2375826Medicaid