Healthcare Provider Details

I. General information

NPI: 1558043745
Provider Name (Legal Business Name): MOHAMED BERRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-3018
US

IV. Provider business mailing address

1120 15TH ST
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-9442
  • Fax:
Mailing address:
  • Phone: 706-721-9442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT229739
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: