Provider Demographics
NPI:1558472977
Name:ISLAM, MOHAMMED NAZRUL (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:NAZRUL
Last Name:ISLAM
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 1:23 ANNAPOLIS DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3833
Mailing Address - Country:US
Mailing Address - Phone:267-779-5239
Mailing Address - Fax:
Practice Address - Street 1:243 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-2201
Practice Address - Country:US
Practice Address - Phone:609-267-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA079180002084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0083577Medicaid
NJ1453554Medicare UPIN
NJ095864Medicare ID - Type Unspecified