Provider Demographics
NPI:1477588747
Name:ISMAIL, MOHAMMED (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:
Last Name:ISMAIL
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 1:46 THIRD ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12188
Mailing Address - Country:US
Mailing Address - Phone:518-237-0641
Mailing Address - Fax:518-235-6401
Practice Address - Street 1:1300 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1628
Practice Address - Country:US
Practice Address - Phone:518-268-5542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119154207R00000X, 207RG0300X, 207RP1001X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00540372Medicaid
D74792Medicare UPIN
NY53949BMedicare PIN
NY00540372Medicaid