Provider Demographics
NPI:1760479786
Name:AL-JASIM, MOHAMMED M (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:M
Last Name:AL-JASIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMMED
Other - Middle Name:ABDULRIDHA
Other - Last Name:MOHAMMED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3156
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92244-3156
Mailing Address - Country:US
Mailing Address - Phone:760-336-3773
Mailing Address - Fax:760-370-3229
Practice Address - Street 1:1600 S IMPERIAL AVE
Practice Address - Street 2:SUITE #8
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4242
Practice Address - Country:US
Practice Address - Phone:760-336-3773
Practice Address - Fax:760-370-3229
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82827207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760479786Medicaid
CA1760479786Medicaid
CAA82827Medicare PIN