=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255330569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMED AMIRUL ISLAM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3921 N TWIN CITY HWY
-----------------------------------------------------
City | PORT ARTHUR
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77642-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-963-0000
-----------------------------------------------------
Fax | 409-963-1899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 951406
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75395-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-963-0000
-----------------------------------------------------
Fax | 409-963-1899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | L4981
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207UN0901X
-----------------------------------------------------
Taxonomy Name | Nuclear Cardiology Physician
-----------------------------------------------------
License Number | L4981
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------