Healthcare Provider Details

I. General information

NPI: 1063504033
Provider Name (Legal Business Name): MOHAMMAD MAHMUDUR RAHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17012 HIGHLAND AVE UNIT 101
JAMAICA NY
11432-2782
US

IV. Provider business mailing address

18310 DALNY RD JAMAICA ESTATES
JAMAICA NY
11432-2465
US

V. Phone/Fax

Practice location:
  • Phone: 718-864-8882
  • Fax:
Mailing address:
  • Phone: 718-864-8882
  • Fax: 718-383-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number211211
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: