Healthcare Provider Details

I. General information

NPI: 1033643960
Provider Name (Legal Business Name): MOHAMMED TASHFIQUL ISLAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S LIMESTONE
LEXINGTON KY
40536-4142
US

IV. Provider business mailing address

109 W 27TH ST RM 5S
NEW YORK NY
10001-6208
US

V. Phone/Fax

Practice location:
  • Phone: 859-226-7063
  • Fax: 859-226-7266
Mailing address:
  • Phone: 833-351-8255
  • Fax: 888-815-3583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number315847
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number57492
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number57492
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: