Provider Demographics
NPI:1083722292
Name:MOIZUDDIN, MOHAMMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:MOIZUDDIN
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 1:1022 KENILWORTH ST
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5828
Mailing Address - Country:US
Mailing Address - Phone:972-674-9910
Mailing Address - Fax:
Practice Address - Street 1:5012 S US HIGHWAY 75 STE 205
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4635
Practice Address - Country:US
Practice Address - Phone:972-674-9910
Practice Address - Fax:972-666-5959
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2022-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP061207RS0012X, 207RP1001X
TXR7825207RP1001X
LAMD200298207RP1001X
WI48038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX405865301Medicaid
WI34821200Medicaid
I39417Medicare UPIN