Provider Demographics
NPI:1972852382
Name:ISMAIL, ISMAIL MOHAMED
Entity Type:Individual
Prefix:
First Name:ISMAIL
Middle Name:MOHAMED
Last Name:ISMAIL
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 1:3116 S MILL AVE STE 254
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-3678
Mailing Address - Country:US
Mailing Address - Phone:602-405-0905
Mailing Address - Fax:
Practice Address - Street 1:2519 E THOMAS RD STE B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7913
Practice Address - Country:US
Practice Address - Phone:602-405-0905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)