Provider Demographics
NPI:1689625253
Name:MOHIDIN, MUMTAZ
Entity Type:Individual
Prefix:DR
First Name:MUMTAZ
Middle Name:
Last Name:MOHIDIN
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 1:431 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2315
Mailing Address - Country:US
Mailing Address - Phone:631-376-1101
Mailing Address - Fax:631-376-1139
Practice Address - Street 1:431 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-2315
Practice Address - Country:US
Practice Address - Phone:631-376-1101
Practice Address - Fax:631-376-1139
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184482207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2511488OtherGHI
NY184482OtherLICENSE
NY3X1011OtherEMPIRE BCBS
NY3X1011OtherEMPIRE BCBS
NYF83419Medicare UPIN