MEDICARE: BADRADDIN MANSOUR MOHAMAD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	0401419887	VA

General Provider Information

NPI Number	:	1790638518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BADRADDIN MANSOUR MOHAMAD

Provider Business Mailing Address
First Line	:	125 BARNOSKY CT APT 125
Second Line	:
City	:	SOUTH PLAINFIELD
State	:	NJ
Zip	:	07080-2538
Country	:	US
Telephone Number	:	407-881-3323
Fax Number	:

Provider Business Practice Location Address
First Line	:	1280 CONCORD AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-6518
Country	:	US
Telephone Number	:	804-261-4871
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2026
Last Update Date	:	02/19/2026

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