Provider Demographics
NPI:1205959723
Name:MOHAM, WILLIE
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:MOHAM
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 1:101 N ZANG BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4528
Mailing Address - Country:US
Mailing Address - Phone:214-948-2417
Mailing Address - Fax:
Practice Address - Street 1:101 N ZANG BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4528
Practice Address - Country:US
Practice Address - Phone:214-948-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator