Provider Demographics
NPI:1891764379
Name:MUJEEBUDDIN, MOHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:MUJEEBUDDIN
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 1:1012 WINSTON CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-5141
Mailing Address - Country:US
Mailing Address - Phone:804-458-8583
Mailing Address - Fax:804-541-2724
Practice Address - Street 1:1012 WINSTON CHURCHILL DR
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-5141
Practice Address - Country:US
Practice Address - Phone:804-458-8583
Practice Address - Fax:804-541-2724
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006040853Medicaid
VAC02208Medicare PIN
VA006040853Medicaid