Healthcare Provider Details

I. General information

NPI: 1861659625
Provider Name (Legal Business Name): NIZAM UD DIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-909-7735
Mailing address:
  • Phone: 508-765-9771
  • Fax: 508-909-7735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101266349
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number238494
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101266349
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: