Basic Information
| Provider Information | |||||||||
| NPI: | 1215152442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMIUDDIN | ||||||||
| FirstName: | MOHAMMED | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 REPUBLIC PKWY | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT. | ||||||||
| City: | MESQUITE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751506916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722797575 | ||||||||
| FaxNumber: | 9722700197 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S COULTER ST | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063513777 | ||||||||
| FaxNumber: | 8063513765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2007 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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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 | 207Q00000X | M6862 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0300X | M6862 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 24906026 | 05 | NM | MEDICAID | 200120680 A | 05 | OK | MEDICAID | 188160901 | 05 | TX | MEDICAID |