Healthcare Provider Details

I. General information

NPI: 1982798302
Provider Name (Legal Business Name): KAZI M ISLAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 06/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 E LA CROSSE AVE
LANSDOWNE PA
19050-2002
US

IV. Provider business mailing address

1025 CAPIE POLK DRIVE
SPRINGFIELD PA
19064
US

V. Phone/Fax

Practice location:
  • Phone: 610-394-2130
  • Fax: 610-394-2177
Mailing address:
  • Phone: 610-544-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD051940L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1466911
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: