=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912534652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMED OSMAN AHMED
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2020
-----------------------------------------------------
Last Update Date | 03/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 N COUNTRY RD
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-473-1320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 LEE ST BOX 801210
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22908-0816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-924-5314
-----------------------------------------------------
Fax | 434-243-4743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 33062101
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------