Healthcare Provider Details

I. General information

NPI: 1629299037
Provider Name (Legal Business Name): MOHAMMED QUSIM ESMAILZADA MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

692 MIDDLE COUNTRY RD
SELDEN NY
11784-2537
US

IV. Provider business mailing address

69 ASHLAND DR
KINGS PARK NY
11754-4018
US

V. Phone/Fax

Practice location:
  • Phone: 631-979-0571
  • Fax:
Mailing address:
  • Phone: 631-979-0571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: