Healthcare Provider Details

I. General information

NPI: 1770606063
Provider Name (Legal Business Name): MAHJABEEN ISLAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAHJABEEN ISLAM M.D.

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 ILLINOIS AVE STE E
MAUMEE OH
43537-1744
US

IV. Provider business mailing address

959 ILLINOIS AVE STE E
MAUMEE OH
43537-1744
US

V. Phone/Fax

Practice location:
  • Phone: 419-872-0500
  • Fax: 419-874-4650
Mailing address:
  • Phone: 419-872-0500
  • Fax: 419-874-4650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.053406
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberOH053406
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: