Provider Demographics
NPI:1124028006
Name:KAZIMUDDIN, NISARFATHIMA (MD)
Entity Type:Individual
Prefix:
First Name:NISARFATHIMA
Middle Name:
Last Name:KAZIMUDDIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NISARFATHIMA
Other - Middle Name:
Other - Last Name:ABDULWAHEED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:825 SECOND AVE
Mailing Address - Street 2:STE B1
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101
Mailing Address - Country:US
Mailing Address - Phone:270-782-0151
Mailing Address - Fax:270-782-7528
Practice Address - Street 1:825 SECOND AVE
Practice Address - Street 2:STE B1
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-782-0151
Practice Address - Fax:270-782-7528
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36859207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64044639Medicaid
KYH67413Medicare UPIN
KY64044639Medicaid