1528353307 NPI number — MR. WALI SHAREEF MUHAMMAD MBA

Table of content: MR. WALI SHAREEF MUHAMMAD MBA (NPI 1528353307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528353307 NPI number — MR. WALI SHAREEF MUHAMMAD MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUHAMMAD
Provider First Name:
WALI
Provider Middle Name:
SHAREEF
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MBA
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:
1528353307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 HUNT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06512-1104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-936-9254
Provider Business Mailing Address Fax Number:
203-823-4470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 HOSLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
BRANFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06405-2523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-936-9254
Provider Business Practice Location Address Fax Number:
203-823-4470
Provider Enumeration Date:
06/09/2011

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008030395 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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