Basic Information
| Provider Information | |||||||||
| NPI: | 1760479786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AL-JASIM | ||||||||
| FirstName: | MOHAMMED | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOHAMMED | ||||||||
| OtherFirstName: | MOHAMMED | ||||||||
| OtherMiddleName: | ABDULRIDHA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3156 | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922443156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603363773 | ||||||||
| FaxNumber: | 7603703229 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S IMPERIAL AVE | ||||||||
| Address2: | SUITE #8 | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603363773 | ||||||||
| FaxNumber: | 7603703229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 11/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A82827 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | A82827 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 1760479786 | 05 | CA | MEDICAID |