Healthcare Provider Details

I. General information

NPI: 1700012804
Provider Name (Legal Business Name): M. FARRUKH NIZAM, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 JAMES ST SUITE 301
EDISON NJ
08820-3902
US

IV. Provider business mailing address

98 JAMES ST SUITE 301
EDISON NJ
08820-3902
US

V. Phone/Fax

Practice location:
  • Phone: 732-494-0100
  • Fax: 732-494-0114
Mailing address:
  • Phone: 732-494-0100
  • Fax: 732-494-0114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: MOHAMMED FARRUKH NIZAM
Title or Position: PHYSICIAN
Credential: MD
Phone: 732-494-0100