Provider Demographics
NPI:1801866405
Name:FAISAL, MOHAMMAD A (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:A
Last Name:FAISAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3009
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-3009
Mailing Address - Country:US
Mailing Address - Phone:386-758-5985
Mailing Address - Fax:386-758-5987
Practice Address - Street 1:1283 SW STATE ROAD 47
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0489
Practice Address - Country:US
Practice Address - Phone:386-758-5985
Practice Address - Fax:386-758-5987
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58587207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051283400Medicaid
FL051283400Medicaid
FLA62780Medicare UPIN