Provider Demographics
NPI:1588227474
Name:ISLAM, MIMSA (MD)
Entity Type:Individual
Prefix:
First Name:MIMSA
Middle Name:
Last Name:ISLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 8TH AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-5205
Mailing Address - Country:US
Mailing Address - Phone:650-318-9544
Mailing Address - Fax:
Practice Address - Street 1:8900 VAN WYCK EXPY
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2832
Practice Address - Country:US
Practice Address - Phone:718-206-6768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA183132207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine