Provider Demographics
NPI:1265697957
Name:GHALICHI, MOHAMMAD (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:GHALICHI
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 1:8631 W 3RD ST STE 815E
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:832-221-0989
Mailing Address - Fax:
Practice Address - Street 1:8631 W 3RD ST STE 815E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:424-340-5222
Practice Address - Fax:424-206-4938
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1311207R00000X, 207RC0000X
CAA103682207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323128402Medicaid
TX323128403Medicaid
TX323128404Medicaid
TX304999YKTXMedicare PIN
TX304999YKTVMedicare PIN
TX323128404Medicaid