Provider Demographics
NPI:1053402610
Name:RAHMAN, MAHFUZUR (MD)
Entity type:Individual
Prefix:MR
First Name:MAHFUZUR
Middle Name:
Last Name:RAHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 GOODMAN RD E
Mailing Address - Street 2:STE 2
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9530
Mailing Address - Country:US
Mailing Address - Phone:662-349-1750
Mailing Address - Fax:662-349-2350
Practice Address - Street 1:728 GOODMAN RD E
Practice Address - Street 2:STE 2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9530
Practice Address - Country:US
Practice Address - Phone:662-349-1750
Practice Address - Fax:662-349-2350
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000012769207R00000X
MS10172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS110001517OtherMEDICARE
TN3181081Medicaid
TN33309OtherBCBS
TN110007796OtherRR MEDICARE
MS110001517OtherMEDICARE
TN3181081Medicaid