Healthcare Provider Details

I. General information

NPI: 1033166830
Provider Name (Legal Business Name): MOHAMMAD ROIDAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 LOCUST AVE
FAIRMONT WV
26554-1319
US

IV. Provider business mailing address

1614 LOCUST AVE
FAIRMONT WV
26554-1319
US

V. Phone/Fax

Practice location:
  • Phone: 304-363-6659
  • Fax: 304-366-3464
Mailing address:
  • Phone: 304-363-6659
  • Fax: 304-366-3464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number12336
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: