Provider Demographics
NPI:1407895089
Name:NIZAM, MOHAMMED (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:
Last Name:NIZAM
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 1:950 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0320
Mailing Address - Country:US
Mailing Address - Phone:212-861-1400
Mailing Address - Fax:631-953-0019
Practice Address - Street 1:950 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0320
Practice Address - Country:US
Practice Address - Phone:212-861-1400
Practice Address - Fax:631-953-0019
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170248207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01501720Medicaid
NY53G081Medicare PIN
F90250Medicare UPIN