Provider Demographics
NPI:1720568728
Name:MOHAMED GHOUSE, AALIA FATHIMA (MD)
Entity Type:Individual
Prefix:
First Name:AALIA FATHIMA
Middle Name:
Last Name:MOHAMED GHOUSE
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 1:295 VARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-2134
Mailing Address - Country:US
Mailing Address - Phone:978-937-6439
Mailing Address - Fax:
Practice Address - Street 1:46 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1481
Practice Address - Country:US
Practice Address - Phone:207-474-5121
Practice Address - Fax:207-858-2415
Is Sole Proprietor?:No
Enumeration Date:2018-08-19
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA291422207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program