Basic Information
| Provider Information | |||||||||
| NPI: | 1952864829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMIDI | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MBBS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1501 N. CAMPBELL AVE, ROOM 4334 | ||||||||
| Address2: | PO BOX 245058 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206267747 | ||||||||
| FaxNumber: | 5206262247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 N CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857240001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206267747 | ||||||||
| FaxNumber: | 5206262247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2019 | ||||||||
| LastUpdateDate: | 10/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | R77276 | AZ | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.