Basic Information
| Provider Information | |||||||||
| NPI: | 1083611917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAMSHEH | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | WALID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 920 ELKRIDGE LANDING RD | ||||||||
| Address2: | |||||||||
| City: | LINTHICUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106842031 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 404 BYRN ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216131910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102210448 | ||||||||
| FaxNumber: | 4102211377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D38181 | MD | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 528571200 | 05 | MD | MEDICAID |