1336455112 NPI number — DR. SAMAH O MOHIUDDIN MD

Table of content: DR. SAMAH O MOHIUDDIN MD (NPI 1336455112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336455112 NPI number — DR. SAMAH O MOHIUDDIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOHIUDDIN
Provider First Name:
SAMAH
Provider Middle Name:
O
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:
1336455112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 FACTORY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13601-2729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-782-4207
Provider Business Mailing Address Fax Number:
315-782-8699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1340 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601-4541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-782-9003
Provider Business Practice Location Address Fax Number:
315-782-9010
Provider Enumeration Date:
08/31/2010

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: 2084N0400X , with the licence number:  266512 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0400X , with the licence number: 266512-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PENDING . This is a "COMMERCIAL" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 03283901 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: PENDING . This is a "COMMERCIAL INSURANCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 108405200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com