Healthcare Provider Details

I. General information

NPI: 1154316289
Provider Name (Legal Business Name): KAMAL REZA TALUKDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 COSHOCTON AVE
MOUNT VERNON OH
43050
US

IV. Provider business mailing address

1330 COSHOCTON AVE
MOUNT VERNON OH
43050
US

V. Phone/Fax

Practice location:
  • Phone: 740-393-9000
  • Fax: 740-392-0167
Mailing address:
  • Phone: 740-393-9000
  • Fax: 740-392-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-07-1563-T
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: