Provider Demographics
NPI:1861448110
Name:HACENA, MOKHTAR (MD)
Entity Type:Individual
Prefix:
First Name:MOKHTAR
Middle Name:
Last Name:HACENA
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 1:2054 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3634
Mailing Address - Country:US
Mailing Address - Phone:478-918-0770
Mailing Address - Fax:478-918-0771
Practice Address - Street 1:2054 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3634
Practice Address - Country:US
Practice Address - Phone:478-918-0770
Practice Address - Fax:478-918-0771
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055062207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA257348755BMedicaid
GAP00332224OtherMEDICARE RAILROAD#
H71865Medicare UPIN
GA11SCDVCMedicare ID - Type Unspecified
GAGRP4294Medicare PIN