Healthcare Provider Details

I. General information

NPI: 1285167023
Provider Name (Legal Business Name): MOHAMMED ABDULFATAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2017
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1768 VILLAGE PARK DR
ORANGEBURG SC
29118-2457
US

IV. Provider business mailing address

8379 W SUNSET RD STE 210
LAS VEGAS NV
89113-2243
US

V. Phone/Fax

Practice location:
  • Phone: 803-359-2224
  • Fax: 803-539-2234
Mailing address:
  • Phone: 702-968-2437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10955488-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD048499
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD88665
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: