Provider Demographics
NPI:1043445927
Name:MAZUMDER, MOHAMMED AKHLACK HOSSAIN (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:AKHLACK HOSSAIN
Last Name:MAZUMDER
Suffix:
Gender:M
Credentials:MD
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:742 OLD 114
Mailing Address - Street 2:APT # 2
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-8300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:92 PICKETT LN
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-8569
Practice Address - Country:US
Practice Address - Phone:606-874-0112
Practice Address - Fax:606-874-0115
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT194879207Q00000X
IN01068828A.207Q00000X
KY43704363LP2300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care