Provider Demographics
NPI:1366672115
Name:ISLAM, RANEEM S (DO)
Entity Type:Individual
Prefix:
First Name:RANEEM
Middle Name:S
Last Name:ISLAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7400
Mailing Address - Fax:508-941-6200
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:508-941-7400
Practice Address - Fax:508-941-6200
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254434207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095811AMedicaid
MA110095811AMedicaid