Healthcare Provider Details

I. General information

NPI: 1013334309
Provider Name (Legal Business Name): MARJAN ISLAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

235 E 95TH ST APT 17D
NEW YORK NY
10128-4019
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-6054
  • Fax: 718-652-8384
Mailing address:
  • Phone: 205-915-8881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number288420
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number288420
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: