Provider Demographics
NPI:1043082951
Name:ISLAM, MD KHADIMUL
Entity Type:Individual
Prefix:
First Name:MD KHADIMUL
Middle Name:
Last Name:ISLAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 PRESTON RD FL 1
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3626
Mailing Address - Country:US
Mailing Address - Phone:347-285-5909
Mailing Address - Fax:
Practice Address - Street 1:434 MONROE AVE
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-2236
Practice Address - Country:US
Practice Address - Phone:607-324-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP125481207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine