Basic Information
| Provider Information | |||||||||
| NPI: | 1356429625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUKADDAM | ||||||||
| FirstName: | SHAZIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542817700 | ||||||||
| FaxNumber: | 9547157603 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 COCONUT CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | MARGATE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330633913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542817700 | ||||||||
| FaxNumber: | 9547157603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA08136600 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME129980 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0125661 | 05 | NJ | MEDICAID |