Provider Demographics
NPI:1063450591
Name:ELFAYOUMI, ISLAM M (MD)
Entity Type:Individual
Prefix:
First Name:ISLAM
Middle Name:M
Last Name:ELFAYOUMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:CARLSTADT
Mailing Address - State:NJ
Mailing Address - Zip Code:07072-1414
Mailing Address - Country:US
Mailing Address - Phone:732-986-4965
Mailing Address - Fax:201-507-0417
Practice Address - Street 1:350 BOULEVARD
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-2840
Practice Address - Country:US
Practice Address - Phone:973-365-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95068207R00000X
NJ25MA08506700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0197769Medicaid
FL275330800Medicaid
FL52550OtherBCBS
FLP00471993OtherRR MEDICARE
PAP00765998OtherRR MEDICARE
NJP00829446OtherRR MEDICARE
FL275330800Medicaid
NJ0197769Medicaid
NJ147701ZC8AMedicare PIN
PAP00765998OtherRR MEDICARE