Provider Demographics
NPI:1982798302
Name:ISLAM, KAZI M (MD)
Entity type:Individual
Prefix:
First Name:KAZI
Middle Name:M
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 1:1025 CAPIE POLK DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064
Mailing Address - Country:US
Mailing Address - Phone:610-544-1512
Mailing Address - Fax:
Practice Address - Street 1:23 E LA CROSSE AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-2002
Practice Address - Country:US
Practice Address - Phone:610-394-2130
Practice Address - Fax:610-394-2177
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051940L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1466911Medicaid
PAF83056Medicare UPIN