=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245923325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MJMD PRIMARY CARE AND AESTHETIC MEDICINE CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2023
-----------------------------------------------------
Last Update Date | 04/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3721 S STONEBRIDGE DR UNIT 703
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-0234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-548-4995
-----------------------------------------------------
Fax | 855-592-2912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 LONGWOOD DR
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-2954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-550-4997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAYSSARA JUBORI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 313-550-4997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------