Provider Demographics
NPI:1629066964
Name:BAKDASH, MOHAMMED M (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:M
Last Name:BAKDASH
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 1:4515 MARSHA SHARP FWY
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-2520
Mailing Address - Country:US
Mailing Address - Phone:806-744-7223
Mailing Address - Fax:806-740-3325
Practice Address - Street 1:4515 MARSHA SHARP FWY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2520
Practice Address - Country:US
Practice Address - Phone:806-744-7223
Practice Address - Fax:806-740-3325
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2132207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4393386OtherAETNA
TX1286387 08Medicaid
TX107931110OtherFIRSTCARE (GRACE CLINIC)
TX8V8694OtherBCBS-TX (GRACE CLINIC DR)
TX8F3392Medicare ID - Type UnspecifiedGRACE CLINIC PHYSICIAN
TX1286387 08Medicaid
TX107931110OtherFIRSTCARE (GRACE CLINIC)