=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750361697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NAYYER U ISLAM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2006
-----------------------------------------------------
Last Update Date | 10/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2230 TOWNE LAKE PARKWAY BLDG, NO. 900, SUITE 250 & 150
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30189-5540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-556-9222
-----------------------------------------------------
Fax | 404-556-9222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1416 FALKIRK LN NW
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30152-8299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-462-3460
-----------------------------------------------------
Fax | 770-727-0809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 055603
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------