Provider Demographics
NPI:1235369463
Name:ISLAM, ALI MOHAMMED WALIUL (DO)
Entity Type:Individual
Prefix:DR
First Name:ALI MOHAMMED
Middle Name:WALIUL
Last Name:ISLAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:ALI
Other - Middle Name:W
Other - Last Name:ISLAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2604 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-1199
Mailing Address - Country:US
Mailing Address - Phone:718-292-0100
Mailing Address - Fax:718-866-0151
Practice Address - Street 1:5 GRACE CHURCH ST
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-4911
Practice Address - Country:US
Practice Address - Phone:914-937-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03147037Medicaid