Healthcare Provider Details

I. General information

NPI: 1053310409
Provider Name (Legal Business Name): MOHAMMED KAZIMUDDIN MD FACC FSCAI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 SECOND AVE STE B1
BOWLING GREEN KY
42101
US

IV. Provider business mailing address

825 SECOND AVE STE B1
BOWLING GREEN KY
42101
US

V. Phone/Fax

Practice location:
  • Phone: 270-782-0151
  • Fax: 270-782-7528
Mailing address:
  • Phone: 270-782-0151
  • Fax: 270-782-7528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number36951
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: