Provider Demographics
NPI:1245205012
Name:ISLAM, MOHAMMED QAMRUL (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:QAMRUL
Last Name:ISLAM
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 1:4027 74TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5603
Mailing Address - Country:US
Mailing Address - Phone:718-424-1300
Mailing Address - Fax:718-883-1311
Practice Address - Street 1:40-27, 74TH STREET
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11040-2505
Practice Address - Country:US
Practice Address - Phone:718-424-1300
Practice Address - Fax:718-424-1311
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248033204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400092328OtherMEDICARE
NYA100092321OtherMEDICARE GROUP
NYH61304Medicare UPIN
KY183857Medicare PIN
KYH61304Medicare UPIN
KY00237004Medicare PIN
KY65928376Medicaid