Healthcare Provider Details

I. General information

NPI: 1972202521
Provider Name (Legal Business Name): MAHMUD OGO KANJORA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 HEMLOCK ST
BROCKTON MA
02302-3819
US

IV. Provider business mailing address

43 HEMLOCK ST
BROCKTON MA
02302-3819
US

V. Phone/Fax

Practice location:
  • Phone: 774-623-5942
  • Fax:
Mailing address:
  • Phone: 774-623-5942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP70163575
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2264382
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: