Basic Information
| Provider Information | |||||||||
| NPI: | 1184801367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDULLAH | ||||||||
| FirstName: | JAVED | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | DEPT # 960 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017630200 | ||||||||
| FaxNumber: | 9017614002 | ||||||||
| Practice Location | |||||||||
| Address1: | 4250 BETHEL RD | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | OLIVE BRANCH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386548737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017630200 | ||||||||
| FaxNumber: | 9017614002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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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 | 207RI0011X | 50265 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 23973 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 6041886 | 01 | TN | BCBS | OTHER | 06926726 | 05 | MS | MEDICAID | Q002944 | 05 | TN | MEDICAID |