Basic Information
Provider Information | |||||||||
NPI: | 1902834930 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AMIN | ||||||||
FirstName: | MUHAMMAD | ||||||||
MiddleName: | MUDASSAR | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AMIN | ||||||||
OtherFirstName: | HAFIZ | ||||||||
OtherMiddleName: | MUHAMMED MUDASSAR | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1600 E EVERGREEN | ||||||||
Address2: |   | ||||||||
City: | CAMERON | ||||||||
State: | MO | ||||||||
PostalCode: | 644290557 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8166322101 | ||||||||
FaxNumber: | 8166493383 | ||||||||
Practice Location | |||||||||
Address1: | 409 WEST AUBERRY GROVE | ||||||||
Address2: |   | ||||||||
City: | JAMESPORT | ||||||||
State: | MO | ||||||||
PostalCode: | 64648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6606846252 | ||||||||
FaxNumber: | 6606846254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 02/04/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2008029327 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 785000002 | 01 | MO | MEDICARE PART B | OTHER |