Provider Demographics
NPI:1770641391
Name:RAHMAN, MOHAMMAD M
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:M
Last Name:RAHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-3411
Mailing Address - Country:US
Mailing Address - Phone:718-986-5802
Mailing Address - Fax:
Practice Address - Street 1:1219 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-3411
Practice Address - Country:US
Practice Address - Phone:718-986-5802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230021174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02526630Medicaid
NY252AJ1Medicare ID - Type Unspecified
NYI21593Medicare UPIN