1063504033 NPI number — DR. MOHAMMAD MAHMUDUR RAHMAN MD

Table of content: DR. MOHAMMAD MAHMUDUR RAHMAN MD (NPI 1063504033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063504033 NPI number — DR. MOHAMMAD MAHMUDUR RAHMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAHMAN
Provider First Name:
MOHAMMAD
Provider Middle Name:
MAHMUDUR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063504033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18310 DALNY RD
Provider Second Line Business Mailing Address:
JAMAICA ESTATES
Provider Business Mailing Address City Name:
JAMAICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11432-2465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-864-8882
Provider Business Mailing Address Fax Number:
718-383-8047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17012 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
UNIT 101
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11432-2782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-864-8882
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X , with the licence number:  211211 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01902643 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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