Healthcare Provider Details

I. General information

NPI: 1407938384
Provider Name (Legal Business Name): TAJUDEEN A KASHIMAWO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 COLUMBIA RD
ROCKVILLE CENTRE NY
11570-1316
US

IV. Provider business mailing address

1600 E C STREET
BUTNER NC
27509
US

V. Phone/Fax

Practice location:
  • Phone: 516-884-2900
  • Fax:
Mailing address:
  • Phone: 919-575-1940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number153423
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: