Provider Demographics
NPI:1841240231
Name:MOHAMED, KHALED (MD)
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:MOHAMED
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 1:4300B W RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2568
Mailing Address - Country:US
Mailing Address - Phone:228-863-7393
Mailing Address - Fax:228-868-6643
Practice Address - Street 1:4300B W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2568
Practice Address - Country:US
Practice Address - Phone:228-863-7393
Practice Address - Fax:228-868-6643
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27664207RN0300X
MO2005012191207RN0300X
GA065587207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207590803Medicaid
MO207590803Medicaid
MO936855236Medicare PIN
MO936851442Medicare PIN
MOI45227Medicare UPIN
MOP00259178Medicare PIN