Provider Demographics
NPI:1891201240
Name:SHAHID, MOHAMMAD
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:SHAHID
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 1:8 GAYLORD RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR LOCKS
Mailing Address - State:CT
Mailing Address - Zip Code:06096-2815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 GAYLORD RD
Practice Address - Street 2:
Practice Address - City:WINDSOR LOCKS
Practice Address - State:CT
Practice Address - Zip Code:06096-2815
Practice Address - Country:US
Practice Address - Phone:860-692-4104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT$$$$$$$$$Medicaid