Provider Demographics
NPI:1134234529
Name:MOINUDDIN, MOHAMMED (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:MOINUDDIN
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 2121
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38159
Mailing Address - Country:US
Mailing Address - Phone:901-383-8860
Mailing Address - Fax:901-383-8985
Practice Address - Street 1:6019 WALNUT GROVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-383-8860
Practice Address - Fax:901-383-1194
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN75632085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116595Medicaid
TN53215OtherBCBS
TN3037147Medicaid
AR86221OtherBCBS
MS00116595Medicaid
TN3037147Medicare ID - Type Unspecified