Healthcare Provider Details

I. General information

NPI: 1952413114
Provider Name (Legal Business Name): MOHAMMAD Y SAMARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6540 REFLECTION DR APT 1410
SAN DIEGO CA
92124-5143
US

IV. Provider business mailing address

6540 REFLECTION DR APT 1410
SAN DIEGO CA
92124-5143
US

V. Phone/Fax

Practice location:
  • Phone: 414-793-0115
  • Fax: 414-246-4198
Mailing address:
  • Phone: 414-793-0115
  • Fax: 414-246-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberC171319
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36801
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: