=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114938461
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMED ISLAM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 05/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | RBMC 530 NEW BRUNSWICK AVE DEPT OF INTERNAL MEDICINE
-----------------------------------------------------
City | PERTH AMBOY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-324-5080
-----------------------------------------------------
Fax | 732-324-4669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1808 PLAZA DR
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07095-1127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-675-1035
-----------------------------------------------------
Fax | 732-324-4669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35847
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------