Provider Demographics
NPI:1710996939
Name:RAHMAN, MOHAMMAD M (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:M
Last Name:RAHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOUTH BROOKHAVEN HEALTH CENTER
Mailing Address - Street 2:365 EAST MAIN ST
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-854-1307
Mailing Address - Fax:631-854-1310
Practice Address - Street 1:SOUTH BROOKHAVEN HEALTH CENTER
Practice Address - Street 2:365 EAST MAIN ST
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-854-1307
Practice Address - Fax:631-854-1310
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198792208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01706550Medicaid
NY01706550Medicaid
NY70578Medicare ID - Type Unspecified