Provider Demographics
NPI:1780691923
Name:MEMON, MUHAMMAD ANIS (MD)
Entity type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:ANIS
Last Name:MEMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E BROAD ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6409
Mailing Address - Country:US
Mailing Address - Phone:817-477-5500
Mailing Address - Fax:817-453-5503
Practice Address - Street 1:2800 E BROAD ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6409
Practice Address - Country:US
Practice Address - Phone:817-477-5500
Practice Address - Fax:817-453-5503
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1931174400000X
TX154192207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00262265OtherMEDICARE RR
TX0001NAOtherBCBS
TX180095501Medicaid
TX5915477OtherAETNA
TX5915477OtherAETNA
TXP00262265OtherMEDICARE RR