Provider Demographics
NPI:1972202521
Name:KANJORA, MAHMUD OGO
Entity Type:Individual
Prefix:
First Name:MAHMUD
Middle Name:OGO
Last Name:KANJORA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3819
Mailing Address - Country:US
Mailing Address - Phone:774-623-5942
Mailing Address - Fax:
Practice Address - Street 1:43 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3819
Practice Address - Country:US
Practice Address - Phone:774-623-5942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2264382163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Single Specialty