Provider Demographics
NPI:1164083697
Name:MUKHTARZADA, MOHAMMAD TAMIM (OD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:TAMIM
Last Name:MUKHTARZADA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4801
Mailing Address - Country:US
Mailing Address - Phone:631-244-8844
Mailing Address - Fax:
Practice Address - Street 1:5735 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4801
Practice Address - Country:US
Practice Address - Phone:631-244-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003539152W00000X
NYTUV009480152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist