Healthcare Provider Details

I. General information

NPI: 1861448110
Provider Name (Legal Business Name): MOKHTAR HACENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 WATSON BLVD
WARNER ROBINS GA
31093-3634
US

IV. Provider business mailing address

2054 WATSON BLVD
WARNER ROBINS GA
31093-3634
US

V. Phone/Fax

Practice location:
  • Phone: 478-918-0770
  • Fax: 478-918-0771
Mailing address:
  • Phone: 478-918-0770
  • Fax: 478-918-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number055062
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: