Healthcare Provider Details

I. General information

NPI: 1568465359
Provider Name (Legal Business Name): ABDUL R, NIZAM II M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: A RASHED NIZAM II M.D.

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N MORLEY ST STE 101
MOBERLY MO
65270-2556
US

IV. Provider business mailing address

630 N MORLEY ST STE 101
MOBERLY MO
65270-2556
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-0404
  • Fax: 660-263-1725
Mailing address:
  • Phone: 660-263-0404
  • Fax: 660-263-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number113224
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number113224
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: