Provider Demographics
NPI:1811992878
Name:ISLAM, MOHAMMAD (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:ISLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SOHEL
Other - Middle Name:
Other - Last Name:ISLAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:107 NEWTOWN RD
Mailing Address - Street 2:2C
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4146
Mailing Address - Country:US
Mailing Address - Phone:203-791-9661
Mailing Address - Fax:203-730-4165
Practice Address - Street 1:107 NEWTOWN RD
Practice Address - Street 2:2C
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4146
Practice Address - Country:US
Practice Address - Phone:203-791-9661
Practice Address - Fax:203-730-4165
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2018-03-01
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
CT038143174400000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001381433Medicaid
CTH11838Medicare UPIN
CT001381433Medicaid