Provider Demographics
NPI:1699719187
Name:ISLAM, M. SIRAJ UL (MD)
Entity type:Individual
Prefix:
First Name:M.
Middle Name:SIRAJ UL
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:PO BOX 423009
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34742-3009
Mailing Address - Country:US
Mailing Address - Phone:407-518-1199
Mailing Address - Fax:407-569-1201
Practice Address - Street 1:710 OAK COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4100
Practice Address - Country:US
Practice Address - Phone:407-518-1199
Practice Address - Fax:407-569-1201
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048529207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045481800Medicaid
02632Medicare ID - Type Unspecified
FL045481800Medicaid