Provider Demographics
NPI:1063493211
Name:SHAHABUDDIN, MOHAMMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:SHAHABUDDIN
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 1:165 PURITAN DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1737
Mailing Address - Country:US
Mailing Address - Phone:617-472-4519
Mailing Address - Fax:
Practice Address - Street 1:2100 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5615
Practice Address - Country:US
Practice Address - Phone:617-296-4000
Practice Address - Fax:617-474-3820
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA35707208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2050196Medicaid
MA2050196Medicaid