Provider Demographics
NPI:1114969433
Name:MOHIUDDIN, ISHTIAQUE HOSSAIN
Entity type:Individual
Prefix:DR
First Name:ISHTIAQUE
Middle Name:HOSSAIN
Last Name:MOHIUDDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ISHTIAQUE
Other - Middle Name:H
Other - Last Name:MOHIUDDIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:5221 PARAMOUNT PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5490
Mailing Address - Country:US
Mailing Address - Phone:984-215-4111
Mailing Address - Fax:
Practice Address - Street 1:2936 N ELM ST STE 102
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2981
Practice Address - Country:US
Practice Address - Phone:910-671-6619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP312207RC0000X
CAA067466207RC0000X
FLME108828208M00000X
NC200400922207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137WJMedicaid
NC2031206Medicare ID - Type Unspecified
NC89137WJMedicaid