Provider Demographics
NPI:1629037197
Name:MOHAMMED, GHULAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GHULAM
Middle Name:
Last Name:MOHAMMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N BYRON BUTLER PKWY
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-2315
Mailing Address - Country:US
Mailing Address - Phone:850-223-5400
Mailing Address - Fax:850-223-5401
Practice Address - Street 1:555 N BYRON BUTLER PKWY
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2315
Practice Address - Country:US
Practice Address - Phone:850-223-5400
Practice Address - Fax:850-223-5401
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063587207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
593122517OtherCOMMERCIAL
FL374283100Medicaid
103440Medicare ID - Type Unspecified
F67718Medicare UPIN