Basic Information
| Provider Information | |||||||||
| NPI: | 1063476356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOHAMMED | ||||||||
| FirstName: | TAN LUCIEN | ||||||||
| MiddleName: | HASSAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOHAMMED | ||||||||
| OtherFirstName: | T. LUCIEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
| FaxNumber: | 2065155886 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD # 100374 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650291 | ||||||||
| FaxNumber: | 3522650279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35084772 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD2022-0580 | NM | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME120580 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0299743 | 01 | WA | LABOR & INDUSTRY | OTHER | MD00123 | 01 | WA | AK DSHS | OTHER | 1063476356 | 05 | WA | MEDICAID | 2517208 | 05 | OH | MEDICAID | P01121104 | 01 | WA | RAILROAD MEDICARE | OTHER | 012305300 | 05 | FL | MEDICAID |