Healthcare Provider Details

I. General information

NPI: 1124673223
Provider Name (Legal Business Name): MOZIBUR RAHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 COOLIDGE BLVD FL 3
LAFAYETTE LA
70503-2621
US

IV. Provider business mailing address

316 REDFERN ST
LAFAYETTE LA
70508-4487
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-7679
  • Fax:
Mailing address:
  • Phone: 914-306-0170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number346366
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number318988-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: