Healthcare Provider Details

I. General information

NPI: 1669716858
Provider Name (Legal Business Name): MOHAMMED AHMED ALMANASIF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2012
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR STE 440
FORT WAYNE IN
46845-1672
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-9935
  • Fax: 260-373-9926
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number01083847A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: