Provider Demographics
NPI:1053601005
Name:M.Q. ISLAM PHYSICIAN PLLC
Entity type:Organization
Organization Name:M.Q. ISLAM PHYSICIAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:Q
Authorized Official - Last Name:ISLAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-657-8525
Mailing Address - Street 1:16832 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2640
Mailing Address - Country:US
Mailing Address - Phone:718-657-8525
Mailing Address - Fax:718-657-8526
Practice Address - Street 1:20 OLD COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:MANHASSET HILLS
Practice Address - State:NY
Practice Address - Zip Code:11040-1229
Practice Address - Country:US
Practice Address - Phone:718-657-8525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36373174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H61304Medicare UPIN