Provider Demographics
NPI:1902822257
Name:ISLAM, MOHAMMAD SHAHIDUL (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:SHAHIDUL
Last Name:ISLAM
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 1:23 RAYMOND CT
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4707
Mailing Address - Country:US
Mailing Address - Phone:516-414-3550
Mailing Address - Fax:
Practice Address - Street 1:4012 82ND ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1305
Practice Address - Country:US
Practice Address - Phone:347-218-1827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231649208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0889J1Medicare ID - Type Unspecified