Provider Demographics
NPI:1679130587
Name:RIAZ, MAHUM INAM
Entity Type:Individual
Prefix:
First Name:MAHUM
Middle Name:INAM
Last Name:RIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:631-376-3420
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:434-466-5976
Practice Address - Fax:631-376-3420
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7077207P00000X
390200000X
VA0102208079207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program