Healthcare Provider Details

I. General information

NPI: 1558486456
Provider Name (Legal Business Name): MOHAMMED A MUQTADAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 ROBINSON ST
BINGHAMTON NY
13901-4101
US

IV. Provider business mailing address

1234 NAPIER AVE
SAINT JOSEPH MI
49085-2112
US

V. Phone/Fax

Practice location:
  • Phone: 607-724-1391
  • Fax:
Mailing address:
  • Phone: 269-983-8172
  • Fax: 256-998-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberP51148
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: