Provider Demographics
NPI:1407872443
Name:UDDIN, MOHAMMAD NIZAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:NIZAM
Last Name:UDDIN
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 1:425 JOLIET ST.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311
Mailing Address - Country:US
Mailing Address - Phone:219-227-3621
Mailing Address - Fax:219-865-5401
Practice Address - Street 1:5355 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-5325
Practice Address - Country:US
Practice Address - Phone:219-756-0600
Practice Address - Fax:219-756-0608
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059460A207L00000X
NY228644-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200197890AMedicaid
IN141890TMedicare ID - Type Unspecified
IN200197890AMedicaid