Provider Demographics
NPI:1104510395
Name:MOHAMMED, MACKI
Entity type:Individual
Prefix:
First Name:MACKI
Middle Name:
Last Name:MOHAMMED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MUSTAPHA
Other - Middle Name:
Other - Last Name:MOHAMMED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7004 S 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2265
Mailing Address - Country:US
Mailing Address - Phone:605-215-7364
Mailing Address - Fax:
Practice Address - Street 1:4902 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3440
Practice Address - Country:US
Practice Address - Phone:605-214-8632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program