Healthcare Provider Details

I. General information

NPI: 1699979047
Provider Name (Legal Business Name): MR. MOHAMED ABDI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 E CARLA VISTA PL
CHANDLER AZ
85225-8801
US

IV. Provider business mailing address

951 E CARLA VISTA PL
CHANDLER AZ
85225-8801
US

V. Phone/Fax

Practice location:
  • Phone: 480-776-9439
  • Fax:
Mailing address:
  • Phone: 480-776-9439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberDO4329901
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: