Healthcare Provider Details

I. General information

NPI: 1013205400
Provider Name (Legal Business Name): EKRAM M MOHSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 11/21/2021
Certification Date: 11/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE MEDICAL PLAZA BUILDING SUITE 401
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE MEDICAL PLAZA BUILDING SUITE 401
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-4070
  • Fax:
Mailing address:
  • Phone: 551-996-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25MB09693800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MB09693800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: