1114938461 NPI number — DR. MOHAMMED ISLAM MD

Table of content: DR. MOHAMMED ISLAM MD (NPI 1114938461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114938461 NPI number — DR. MOHAMMED ISLAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISLAM
Provider First Name:
MOHAMMED
Provider Middle Name:
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:
1114938461
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1808 PLAZA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07095-1127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-675-1035
Provider Business Mailing Address Fax Number:
732-324-4669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RBMC 530 NEW BRUNSWICK AVE
Provider Second Line Business Practice Location Address:
DEPT OF INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
PERTH AMBOY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-324-5080
Provider Business Practice Location Address Fax Number:
732-324-4669
Provider Enumeration Date:
08/11/2006

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: 207R00000X , with the licence number:  35847 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 129026 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01004682204 . This is a "AMERICHOICE (MIDDLESEX)" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P00800130 . This is a "RR MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0170241 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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