Basic Information
| Provider Information | |||||||||
| NPI: | 1235345430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOHAMMADU | ||||||||
| FirstName: | FAWZU | ||||||||
| MiddleName: | FUSAINI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOHAMMADU | ||||||||
| OtherFirstName: | FUSAINI | ||||||||
| OtherMiddleName: | F | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603586748 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SAYBROOK RD | ||||||||
| Address2: | SUITE N100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603441801 | ||||||||
| FaxNumber: | 8603588657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 05/01/2017 | ||||||||
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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 | 207Q00000X | 044876 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 44876 | CT | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 008023102 | 05 | CT | MEDICAID | 004236346 | 05 | CT | MEDICAID |