Healthcare Provider Details

I. General information

NPI: 1730471459
Provider Name (Legal Business Name): MOHAMED A GUENENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TSIENNETO RD STE 101
DERRY NH
03038-1584
US

IV. Provider business mailing address

6 TSIENNETO RD STE 101
DERRY NH
03038-1584
US

V. Phone/Fax

Practice location:
  • Phone: 603-434-4193
  • Fax: 603-437-6804
Mailing address:
  • Phone: 603-434-4193
  • Fax: 603-437-6804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR1379
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20397
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: