Basic Information
| Provider Information | |||||||||
| NPI: | 1558823211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UDDIN | ||||||||
| FirstName: | MOHAMMED | ||||||||
| MiddleName: | SHAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | UDDIN | ||||||||
| OtherFirstName: | SHAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2001 W 68TH ST | ||||||||
| Address2: | ATTN: MEDICAL EDUCATION, SUITE 202 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053642107 | ||||||||
| FaxNumber: | 3058228347 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 W 68TH ST | ||||||||
| Address2: | ATTN: MEDICAL EDUCATION, SUITE 202 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053642107 | ||||||||
| FaxNumber: | 3058228347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | TRN29085 | FL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.