Provider Demographics
NPI:1629299037
Name:ESMAILZADA, MOHAMMED QUSIM (MT)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:QUSIM
Last Name:ESMAILZADA
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 ASHLAND DR
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-4018
Mailing Address - Country:US
Mailing Address - Phone:631-979-0571
Mailing Address - Fax:
Practice Address - Street 1:692 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2537
Practice Address - Country:US
Practice Address - Phone:631-979-0571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)