Provider Demographics
NPI:1922094762
Name:QAYYUM, MOHAMMAD U (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:U
Last Name:QAYYUM
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 1:77 WINSOR ST
Mailing Address - Street 2:STE 101
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056
Mailing Address - Country:US
Mailing Address - Phone:413-583-6750
Mailing Address - Fax:413-589-7001
Practice Address - Street 1:77 WINSOR ST
Practice Address - Street 2:STE 101
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056
Practice Address - Country:US
Practice Address - Phone:413-583-6750
Practice Address - Fax:413-589-7001
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA505172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3024750Medicaid
MA3024750Medicaid
C57168Medicare UPIN