Provider Demographics
NPI:1427067644
Name:SALAM, M HANI (MD)
Entity type:Individual
Prefix:
First Name:M HANI
Middle Name:
Last Name:SALAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMED
Other - Middle Name:H
Other - Last Name:ABDEL SALAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10 MONDAVI LN
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2661
Mailing Address - Country:US
Mailing Address - Phone:631-444-5577
Mailing Address - Fax:631-444-5577
Practice Address - Street 1:76 SOUTHAVEN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3745
Practice Address - Country:US
Practice Address - Phone:631-447-8860
Practice Address - Fax:631-447-8862
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01770227Medicaid
NY9X591Medicare ID - Type Unspecified
NY01770227Medicaid