Provider Demographics
NPI:1356429625
Name:MUKADDAM, SHAZIA (MD)
Entity type:Individual
Prefix:
First Name:SHAZIA
Middle Name:
Last Name:MUKADDAM
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 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:954-281-7700
Mailing Address - Fax:954-715-7603
Practice Address - Street 1:5100 COCONUT CREEK PKWY
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-3913
Practice Address - Country:US
Practice Address - Phone:954-281-7700
Practice Address - Fax:954-715-7603
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08136600207R00000X
FLME129980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0125661Medicaid
I65819Medicare UPIN
NJ105512M5NMedicare PIN