Provider Demographics
NPI:1831263458
Name:MOHAMMED, RICHARD S (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:S
Last Name:MOHAMMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:S
Other - Last Name:MOHAMMED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6114 PHEASANT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6984
Mailing Address - Country:US
Mailing Address - Phone:386-295-9363
Mailing Address - Fax:386-231-3094
Practice Address - Street 1:6114 PHEASANT RIDGE DR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-6984
Practice Address - Country:US
Practice Address - Phone:386-295-9363
Practice Address - Fax:386-231-3094
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064855207Q00000X
TXJ4361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC55698OtherMEDICAL LICENSE
MDD74160OtherMEDICAL LICENSE
TXJ4361OtherMEDICAL LICENSE
MEMD19251OtherMEDICAL LICENSE
FL377409100Medicaid
FLME64855OtherSTATE MEDICAL LICENSE
OK29112OtherMEDICAL LICENSE
FL26847VMedicare PIN
MDD74160OtherMEDICAL LICENSE
MEMD19251OtherMEDICAL LICENSE