Basic Information
| Provider Information | |||||||||
| NPI: | 1730747767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISLAM | ||||||||
| FirstName: | MEHRAB | ||||||||
| MiddleName: | TAUSIF | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 561 10TH AVE APT 12D | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100363049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9174957722 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 STATION PLAZA NORTH | ||||||||
| Address2: | SUITE 509 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632381 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2019 | ||||||||
| LastUpdateDate: | 06/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.