Provider Demographics
NPI:1700017712
Name:MOHAMMAD, AJMAL (NP)
Entity Type:Individual
Prefix:MR
First Name:AJMAL
Middle Name:
Last Name:MOHAMMAD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 W 171ST ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-2406
Mailing Address - Country:US
Mailing Address - Phone:310-508-8693
Mailing Address - Fax:
Practice Address - Street 1:4023 MARINE AVE
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260
Practice Address - Country:US
Practice Address - Phone:310-508-8693
Practice Address - Fax:310-508-8693
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP19040163W00000X
CA19040363L00000X, 363LP0808X
CANP 19040363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACZ936ZMedicare PIN