MEDICARE: DR. ABDUL R, NIZAM II M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	113224	MO
2	332H00000X	Eyewear Supplier	113224	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	238605	OTHER	MO	ADVANTRA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568465359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ABDUL R, NIZAM II M.D

Provider Business Mailing Address
First Line	:	630 N MORLEY ST
Second Line	:	STE 101
City	:	MOBERLY
State	:	MO
Zip	:	65270-2556
Country	:	US
Telephone Number	:	660-263-0404
Fax Number	:	660-263-1725

Provider Business Practice Location Address
First Line	:	630 N MORLEY ST
Second Line	:	STE 101
City	:	MOBERLY
State	:	MO
Zip	:	65270-2556
Country	:	US
Telephone Number	:	660-263-0404
Fax Number	:	660-263-1725

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	02/07/2014

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