Provider Demographics
NPI:1548552201
Name:MOHAMED, WASIM S (IDC)
Entity type:Individual
Prefix:MR
First Name:WASIM
Middle Name:S
Last Name:MOHAMED
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280148
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32228-0148
Mailing Address - Country:US
Mailing Address - Phone:904-270-4220
Mailing Address - Fax:904-270-4457
Practice Address - Street 1:2104 MASSEY AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32228-0148
Practice Address - Country:US
Practice Address - Phone:904-270-4220
Practice Address - Fax:904-270-4457
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman