Healthcare Provider Details

I. General information

NPI: 1871798421
Provider Name (Legal Business Name): IRFAN M HISAMUDDIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 OGLETOWN STANTON RD SUITE 134
NEWARK DE
19713-2067
US

IV. Provider business mailing address

PO BOX 7356
LANCASTER PA
17604-7356
US

V. Phone/Fax

Practice location:
  • Phone: 302-738-5300
  • Fax: 302-731-4822
Mailing address:
  • Phone: 410-441-4847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPENDING
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberC1-0011248
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: