Provider Demographics
NPI:1467462069
Name:CHOUDHURY, MOHAMMED G (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:G
Last Name:CHOUDHURY
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:PO BOX 1804
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-1804
Mailing Address - Country:US
Mailing Address - Phone:386-755-9457
Mailing Address - Fax:386-755-3369
Practice Address - Street 1:155 NW ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8837
Practice Address - Country:US
Practice Address - Phone:386-755-9457
Practice Address - Fax:386-755-3369
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68711207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378589100Medicaid
27623ZMedicare ID - Type Unspecified
FL378589100Medicaid