Provider Demographics
NPI:1407222433
Name:EHTISHAM, MUHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:
Last Name:EHTISHAM
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 1:111 BREWSTER ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4474
Mailing Address - Country:US
Mailing Address - Phone:401-729-2258
Mailing Address - Fax:401-729-3343
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4474
Practice Address - Country:US
Practice Address - Phone:401-729-2258
Practice Address - Fax:401-729-3343
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP03485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine