Provider Demographics
NPI:1568465359
Name:NIZAM, ABDUL R, II (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDUL
Middle Name:R,
Last Name:NIZAM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:A
Other - Middle Name:RASHED
Other - Last Name:NIZAM
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:630 N MORLEY ST
Mailing Address - Street 2:STE 101
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-2556
Mailing Address - Country:US
Mailing Address - Phone:660-263-0404
Mailing Address - Fax:660-263-1725
Practice Address - Street 1:630 N MORLEY ST
Practice Address - Street 2:STE 101
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2556
Practice Address - Country:US
Practice Address - Phone:660-263-0404
Practice Address - Fax:660-263-1725
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113224207W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO325927507Medicaid
MO238605OtherADVANTRA
MO209988542Medicaid
MO209988542Medicaid
MO000094863Medicare UPIN
MO4570130001Medicare NSC