Basic Information
| Provider Information | |||||||||
| NPI: | 1184022758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISLAM | ||||||||
| FirstName: | MD MOINUL | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2129 | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797602129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326406600 | ||||||||
| FaxNumber: | 4326404790 | ||||||||
| Practice Location | |||||||||
| Address1: | 6030 W. UNIVERSITY | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326406600 | ||||||||
| FaxNumber: | 4326404790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2014 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA09504 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.