Healthcare Provider Details

I. General information

NPI: 1932109378
Provider Name (Legal Business Name): ABUHUZIEFA ABUBAKR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE ST STE 5254
DAYTON OH
45409-2939
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-4200
  • Fax: 937-208-2678
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number215175
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number25MA07286300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number21821
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number35.080807
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: