1922552967 NPI number — KHALED MOHAMED, MD LLC

Table of content: (NPI 1922552967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922552967 NPI number — KHALED MOHAMED, MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KHALED MOHAMED, MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922552967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 OLD TAVERN RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06477-3450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-830-0813
Provider Business Mailing Address Fax Number:
203-717-0138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 OLD TAVERN RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06477-3450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-830-0813
Provider Business Practice Location Address Fax Number:
203-717-0138
Provider Enumeration Date:
08/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MOHAMED
Authorized Official First Name:
KHALED
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
914-682-0965

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  47217 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1124049861 . This is a "NPI TYPE 1" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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