Provider Demographics
NPI:1396796884
Name:MOHAMED, IMTIAZ (MD)
Entity type:Individual
Prefix:
First Name:IMTIAZ
Middle Name:
Last Name:MOHAMED
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 1:11040 N STATE ROAD 77
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-3606
Mailing Address - Country:US
Mailing Address - Phone:715-934-4321
Mailing Address - Fax:
Practice Address - Street 1:11040 N STATE ROAD 77
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-3606
Practice Address - Country:US
Practice Address - Phone:715-934-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41063207RG0100X
MN56386207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1396796884Medicaid
WI1396796884Medicaid
MN1396796884Medicaid
WI32584300Medicaid
WI00000253Medicare PIN
MN1396796884Medicaid
MN100001035Medicare PIN
MI1396796884Medicaid