Provider Demographics
NPI:1174515761
Name:AL-BASHIR, MOHAMED FAHMI (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:FAHMI
Last Name:AL-BASHIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 68TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-6003
Mailing Address - Country:US
Mailing Address - Phone:718-986-7734
Mailing Address - Fax:201-795-9157
Practice Address - Street 1:550 NEWARK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1326
Practice Address - Country:US
Practice Address - Phone:201-795-9155
Practice Address - Fax:201-795-9157
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ72291208600000X
NY215854208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02316163Medicaid
NJ8578401Medicaid
NY02316163Medicaid
NY46P483Medicare ID - Type Unspecified