Provider Demographics
NPI:1689419723
Name:NIZAMUDDIN, MOHAMMAD
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:NIZAMUDDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 PARLIAMENT PL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5067
Mailing Address - Country:US
Mailing Address - Phone:779-423-3413
Mailing Address - Fax:
Practice Address - Street 1:808 S WOOD ST STE 165
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7306
Practice Address - Country:US
Practice Address - Phone:312-996-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program