Provider Demographics
NPI:1336356740
Name:ISLAM, NAFISA (MD)
Entity Type:Individual
Prefix:
First Name:NAFISA
Middle Name:
Last Name:ISLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 BRUNS DR
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-1112
Mailing Address - Country:US
Mailing Address - Phone:937-838-4928
Mailing Address - Fax:937-838-4928
Practice Address - Street 1:187 BRUNS DR
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-1112
Practice Address - Country:US
Practice Address - Phone:937-838-4928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH094840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4290992Medicare PIN