Provider Demographics
NPI:1942276613
Name:AL-FAWAKHIRI, MUHAMMED R (MD)
Entity Type:Individual
Prefix:MR
First Name:MUHAMMED
Middle Name:R
Last Name:AL-FAWAKHIRI
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 1:975 PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9201
Mailing Address - Country:US
Mailing Address - Phone:262-329-3450
Mailing Address - Fax:
Practice Address - Street 1:975 PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9201
Practice Address - Country:US
Practice Address - Phone:262-329-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54875-20207R00000X
OH35084303A207R00000X
NC2010-01667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2478859Medicaid
341783789032OtherCARE SOURCE
7832578OtherAETNA
000000332478OtherANTHEM
F84303OtherSUMMACARE APEX
0409665OtherUNITED HEALTHCARE
341783789032OtherCARE SOURCE
I10209Medicare UPIN