Provider Demographics
NPI:1316122070
Name:MOHYUDDIN, MOHAMMAD ALI (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:ALI
Last Name:MOHYUDDIN
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 1:101 CRICKET CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576
Mailing Address - Country:US
Mailing Address - Phone:516-353-1221
Mailing Address - Fax:516-326-2273
Practice Address - Street 1:1981 MARCUS AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:LAKE SUSSESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-355-2273
Practice Address - Fax:516-326-2273
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030391183500000X
NY220444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine