Basic Information
| Provider Information | |||||||||
| NPI: | 1932109378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABUBAKR | ||||||||
| FirstName: | ABUHUZIEFA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 E APPLE ST STE 5254 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372084200 | ||||||||
| FaxNumber: | 9372082678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 215175 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 25MA07286300 | NJ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0600X | 21821 | MS | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0600X | 35.080807 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | 0438367 | 05 | OH | MEDICAID | P01236082 | 01 | MS | RR MEDICARE | OTHER | 4836155 | 05 | NY | MEDICAID | 8658307 | 05 | NJ | MEDICAID | 1564923 | 05 | LA | MEDICAID |