Provider Demographics
NPI:1104273291
Name:PRODHAN, MD TAJUL ISLAM (MD)
Entity type:Individual
Prefix:
First Name:MD TAJUL
Middle Name:ISLAM
Last Name:PRODHAN
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 1:201 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16550-0002
Mailing Address - Country:US
Mailing Address - Phone:814-877-4922
Mailing Address - Fax:814-877-3622
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-4922
Practice Address - Fax:814-877-3622
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2022-09-28
Deactivation Date:2017-01-20
Deactivation Code:
Reactivation Date:2017-04-14
Provider Licenses
StateLicense IDTaxonomies
NY303807-01207R00000X
PAMD479217207R00000X
RILP04060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty