Provider Demographics
NPI:1285745653
Name:MOHIUDDIN, M AZAM (MD)
Entity type:Individual
Prefix:
First Name:M AZAM
Middle Name:
Last Name:MOHIUDDIN
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 1:8110 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2803
Mailing Address - Country:US
Mailing Address - Phone:215-695-0331
Mailing Address - Fax:215-695-0325
Practice Address - Street 1:8110 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2803
Practice Address - Country:US
Practice Address - Phone:215-695-0331
Practice Address - Fax:215-695-0325
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-037150L283Q00000X
PAMD037150L2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA063780Medicare ID - Type Unspecified