Provider Demographics
NPI:1073579801
Name:MOHAMMAD, NIZAMUDDIN
Entity Type:Individual
Prefix:MR
First Name:NIZAMUDDIN
Middle Name:
Last Name:MOHAMMAD
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 1:25408 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6200
Mailing Address - Country:US
Mailing Address - Phone:313-299-1877
Mailing Address - Fax:313-299-0746
Practice Address - Street 1:25408 GODDARD RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6200
Practice Address - Country:US
Practice Address - Phone:313-299-1877
Practice Address - Fax:313-299-0746
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236758Medicare ID - Type UnspecifiedMEDICARE PROVIDER PART-B