Healthcare Provider Details

I. General information

NPI: 1669352878
Provider Name (Legal Business Name): MOHAMUD MOKOMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 W HISTORIC MITCHELL ST
MILWAUKEE WI
53204-3308
US

IV. Provider business mailing address

1011 W HISTORIC MITCHELL ST
MILWAUKEE WI
53204-3308
US

V. Phone/Fax

Practice location:
  • Phone: 414-204-4027
  • Fax:
Mailing address:
  • Phone: 414-204-4027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License NumberM2505549700199
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: