Provider Demographics
NPI:1750965737
Name:SIAM, MOHAMED
Entity type:Individual
Prefix:MR
First Name:MOHAMED
Middle Name:
Last Name:SIAM
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 1:2454 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235
Mailing Address - Country:US
Mailing Address - Phone:929-417-6381
Mailing Address - Fax:855-955-3899
Practice Address - Street 1:3311 SHORE PKWY APT FF
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:929-417-6381
Practice Address - Fax:855-955-3899
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2022-11-14
Deactivation Date:2022-05-06
Deactivation Code:
Reactivation Date:2022-06-08
Provider Licenses
StateLicense IDTaxonomies
NY043992-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist