Provider Demographics
NPI:1427497726
Name:MOMIN, SAJEDABANU (MD)
Entity type:Individual
Prefix:
First Name:SAJEDABANU
Middle Name:
Last Name:MOMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3436
Mailing Address - Country:US
Mailing Address - Phone:260-443-4295
Mailing Address - Fax:
Practice Address - Street 1:455 TOLL GATE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2759
Practice Address - Country:US
Practice Address - Phone:260-443-4295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD15600208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist