Healthcare Provider Details

I. General information

NPI: 1942760368
Provider Name (Legal Business Name): MOHAMED MAHMOUD SABOUR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 WESTCHESTER AVE
BRONX NY
10462-4734
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 718-829-6770
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS021008
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number314012
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: