Healthcare Provider Details

I. General information

NPI: 1609214105
Provider Name (Legal Business Name): MOHAMED OTHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 CORNELL RD
CLEVELAND OH
44106-3804
US

IV. Provider business mailing address

12900 LAKE AVE APT 2007
LAKEWOOD OH
44107-1577
US

V. Phone/Fax

Practice location:
  • Phone: 734-277-2897
  • Fax:
Mailing address:
  • Phone: 734-277-2897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414004
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.024057
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: