Provider Demographics
NPI:1952413114
Name:SAMARA, MOHAMMAD Y (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:Y
Last Name:SAMARA
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 1:6540 REFLECTION DR APT 1410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-5143
Mailing Address - Country:US
Mailing Address - Phone:414-793-0115
Mailing Address - Fax:414-246-4198
Practice Address - Street 1:6540 REFLECTION DR APT 1410
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-5143
Practice Address - Country:US
Practice Address - Phone:414-793-0115
Practice Address - Fax:414-246-4198
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC171319207RG0300X
WI36801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI34060001 INDIVIDUAOtherMEDICARE PTAN
WI000073606 GROUPOtherMEDICARE PTAN
WIWI3406 GROUPOtherMEDICARE PTAN
WI00017606 INDIVIDUALOtherMEDICARE PTAN
WI32170400Medicaid
WI32170400Medicaid