Provider Demographics
NPI:1629162052
Name:ISLAM, MOHAMMAD KAMRUL (OD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:KAMRUL
Last Name:ISLAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2964 SILVERMERE LANE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:678-439-1393
Mailing Address - Fax:706-659-3541
Practice Address - Street 1:1871 N ELM ST
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-2349
Practice Address - Country:US
Practice Address - Phone:706-659-3540
Practice Address - Fax:706-659-3541
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2133152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA856421474BMedicaid
GA856421474AMedicaid
GA856421474CMedicaid
GA856421474AMedicaid
GA856421474BMedicaid