Healthcare Provider Details

I. General information

NPI: 1043082951
Provider Name (Legal Business Name): MD KHADIMUL ISLAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 MONROE AVE
HORNELL NY
14843-2236
US

IV. Provider business mailing address

131 PRESTON RD FL 1
CHEEKTOWAGA NY
14215-3626
US

V. Phone/Fax

Practice location:
  • Phone: 607-324-7740
  • Fax:
Mailing address:
  • Phone: 347-285-5909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP125481
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: