Provider Demographics
NPI:1629202841
Name:ISLAM, NAZRUL (MD)
Entity Type:Individual
Prefix:DR
First Name:NAZRUL
Middle Name:
Last Name:ISLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHAMMAD
Other - Middle Name:NAZRUL
Other - Last Name:ISLAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3114 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2217
Mailing Address - Country:US
Mailing Address - Phone:310-408-7804
Mailing Address - Fax:323-726-3870
Practice Address - Street 1:5398 THOMASTON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-8110
Practice Address - Country:US
Practice Address - Phone:478-476-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102426207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine