Provider Demographics
NPI:1124045679
Name:RIZWAN, MOHAMMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:RIZWAN
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 1:108 ASHTON PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8475
Mailing Address - Country:US
Mailing Address - Phone:601-898-3060
Mailing Address - Fax:
Practice Address - Street 1:121 E BAKER ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2450
Practice Address - Country:US
Practice Address - Phone:662-887-5235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14546207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I930851Medicaid