Provider Demographics
NPI:1801874029
Name:MOHAMED, MOUSA S (MD)
Entity type:Individual
Prefix:
First Name:MOUSA
Middle Name:S
Last Name:MOHAMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 N SAGINAW ST
Mailing Address - Street 2:STE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505-5332
Mailing Address - Country:US
Mailing Address - Phone:810-785-1121
Mailing Address - Fax:810-785-3850
Practice Address - Street 1:425O N. SAGINAW ST.
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48505-5332
Practice Address - Country:US
Practice Address - Phone:810-785-1121
Practice Address - Fax:810-785-3850
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301061794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104223480Medicaid
MIOB56031OtherBSBSM GRP
MIOB56031OtherBSBSM GRP
MIP06630001Medicare ID - Type Unspecified
MIG37366Medicare UPIN