Provider Demographics
NPI:1699717504
Name:ISLAM, MD. WAHIDUL (MD)
Entity type:Individual
Prefix:
First Name:MD. WAHIDUL
Middle Name:
Last Name:ISLAM
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 1:5150 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-2738
Mailing Address - Country:US
Mailing Address - Phone:513-874-8111
Mailing Address - Fax:513-860-6992
Practice Address - Street 1:544 PATTERSON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2514
Practice Address - Country:US
Practice Address - Phone:513-896-9595
Practice Address - Fax:513-896-4171
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077851207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2191168Medicaid
OH4249222Medicare PIN
H18030Medicare UPIN