Provider Demographics
NPI:1275189615
Name:TALUKDER, MUSTAKIM (PA)
Entity type:Individual
Prefix:MR
First Name:MUSTAKIM
Middle Name:
Last Name:TALUKDER
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:603-264-8726
Mailing Address - Fax:
Practice Address - Street 1:385 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4357
Practice Address - Country:US
Practice Address - Phone:860-777-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7010363A00000X
390200000X
NH1674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program