Provider Demographics
NPI:1477887735
Name:CHOUDHURY, MAHMOOD HASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHMOOD
Middle Name:HASAN
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 1:3503 S FORESTDALE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-4120
Mailing Address - Country:US
Mailing Address - Phone:417-886-1117
Mailing Address - Fax:
Practice Address - Street 1:3503 S FORESTDALE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-4120
Practice Address - Country:US
Practice Address - Phone:417-886-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2012-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34977207Q00000X
DE34977208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist