Provider Demographics
NPI:1386171312
Name:MEMON, NIAZ (MD)
Entity type:Individual
Prefix:
First Name:NIAZ
Middle Name:
Last Name:MEMON
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:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:617-726-3884
Mailing Address - Fax:
Practice Address - Street 1:801 CENTRAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2529
Practice Address - Country:US
Practice Address - Phone:603-740-9713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2022-10-17
Deactivation Date:2017-12-28
Deactivation Code:
Reactivation Date:2018-01-18
Provider Licenses
StateLicense IDTaxonomies
MO2020018960207R00000X
NH22060207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3135647Medicaid