Provider Demographics
NPI:1265063358
Name:ISLAM, A S M TAZUL (MD)
Entity type:Individual
Prefix:
First Name:A S M
Middle Name:TAZUL
Last Name:ISLAM
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 1:17810 WEXFORD TER APT 4R
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3014
Mailing Address - Country:US
Mailing Address - Phone:347-820-5051
Mailing Address - Fax:
Practice Address - Street 1:9131 175TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5517
Practice Address - Country:US
Practice Address - Phone:718-657-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104094207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine