Provider Demographics
NPI:1295998722
Name:AHMEDUDDIN, MOHAMMED R (DPM)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:R
Last Name:AHMEDUDDIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:305-628-6117
Mailing Address - Fax:
Practice Address - Street 1:2124 CANDLER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032
Practice Address - Country:US
Practice Address - Phone:404-836-0272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4653213E00000X
GAPOD001431213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200982210Medicaid