Basic Information
| Provider Information | |||||||||
| NPI: | 1295055572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOHAMED | ||||||||
| FirstName: | BONITA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 E BELTLINE AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167526235 | ||||||||
| FaxNumber: | 6167526324 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 E BELTLINE AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167526235 | ||||||||
| FaxNumber: | 6167526324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2010 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 4301108356 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1295055572 | 05 | MI | MEDICAID |