1588017164 NPI number — MUBUSHAR IKRAM RAZA

Table of content: MUBUSHAR IKRAM RAZA (NPI 1588017164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588017164 NPI number — MUBUSHAR IKRAM RAZA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAZA
Provider First Name:
MUBUSHAR
Provider Middle Name:
IKRAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1588017164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1757 NEW YORK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON STATION
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11746-2407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-983-3273
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1757 NEW YORK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON STATION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11746-2407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-983-3237
Provider Business Practice Location Address Fax Number:
631-961-8775
Provider Enumeration Date:
07/19/2016

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: 363LA2200X , with the licence number:  307814 , 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: 307814 . This is a "307814" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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