Provider Demographics
NPI:1447252440
Name:ISLAM, SAJJUDAL SR (MD)
Entity type:Individual
Prefix:DR
First Name:SAJJUDAL
Middle Name:
Last Name:ISLAM
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N MUSKINGUM AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5152
Mailing Address - Country:US
Mailing Address - Phone:432-335-8400
Mailing Address - Fax:432-335-5805
Practice Address - Street 1:320 N MUSKINGUM AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5152
Practice Address - Country:US
Practice Address - Phone:432-335-8400
Practice Address - Fax:432-335-5805
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7240174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120388704Medicaid
TXG7240OtherWORK COMP
TX00GE62OtherBLUE CROSS OF TEXAS
TXG7240OtherWORK COMP
TXE21005Medicare UPIN