Provider Demographics
NPI:1366567471
Name:BACCORA, MOHAMMED HOSAM ALDIN (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:HOSAM ALDIN
Last Name:BACCORA
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 1:1701 3RD ST SE
Mailing Address - Street 2:STE 300
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4511
Mailing Address - Country:US
Mailing Address - Phone:253-697-4740
Mailing Address - Fax:
Practice Address - Street 1:1701 3RD ST SE
Practice Address - Street 2:STE 300
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4511
Practice Address - Country:US
Practice Address - Phone:253-697-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00049133207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine