Healthcare Provider Details

I. General information

NPI: 1750488631
Provider Name (Legal Business Name): MOHAMMED N. ISLAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 WAYNE AVE 119 PROF. BLDG, SUITE 103
INDIANA PA
15701-3501
US

IV. Provider business mailing address

9 NORTH 7TH STREET SUITE 203
INDIANA PA
15701-1880
US

V. Phone/Fax

Practice location:
  • Phone: 724-463-1046
  • Fax: 724-463-2314
Mailing address:
  • Phone: 724-357-7196
  • Fax: 724-357-7279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD436442
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD436442
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number195804
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: