Provider Demographics
NPI:1861500506
Name:MOUHAMED IYAD FAKHRI, MD, PA
Entity Type:Organization
Organization Name:MOUHAMED IYAD FAKHRI, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOUHAMED
Authorized Official - Middle Name:IYAD
Authorized Official - Last Name:FAKHRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-590-0009
Mailing Address - Street 1:620 COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328
Mailing Address - Country:US
Mailing Address - Phone:910-590-0009
Mailing Address - Fax:910-590-2465
Practice Address - Street 1:620 COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328
Practice Address - Country:US
Practice Address - Phone:910-590-0009
Practice Address - Fax:910-590-2465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
187178OtherMEDCOST
NC891350KMedicaid
NC1350KOtherBLUE CROSS BLUE SHIELD
187178OtherMEDCOST
I01668Medicare UPIN