Provider Demographics
NPI:1902822901
Name:ISMAIL, SIRAJUDDIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SIRAJUDDIN
Middle Name:
Last Name:ISMAIL
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-474-8921
Mailing Address - Fax:336-474-8923
Practice Address - Street 1:309 PINEYWOOD RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3438
Practice Address - Country:US
Practice Address - Phone:336-474-8921
Practice Address - Fax:336-474-8923
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA075856002084N0402X
NC2007-012482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0005266Medicaid
H96471Medicare UPIN
NJ0005266Medicaid