Healthcare Provider Details

I. General information

NPI: 1225655285
Provider Name (Legal Business Name): MOHAMED ISSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date: 01/17/2022
Reactivation Date: 02/01/2022

III. Provider practice location address

1757 ROCK QUARRY RD STE A
STOCKBRIDGE GA
30281-7303
US

IV. Provider business mailing address

19229 MACK AVE STE 34
GROSSE POINTE WOODS MI
48236-2857
US

V. Phone/Fax

Practice location:
  • Phone: 678-284-6575
  • Fax:
Mailing address:
  • Phone: 313-647-3245
  • Fax: 313-647-3244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number109947
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301508803
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: