Provider Demographics
NPI:1871798421
Name:HISAMUDDIN, IRFAN M (MD)
Entity type:Individual
Prefix:
First Name:IRFAN
Middle Name:M
Last Name:HISAMUDDIN
Suffix:
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:PO BOX 7356
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17604-7356
Mailing Address - Country:US
Mailing Address - Phone:410-441-4847
Mailing Address - Fax:
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 134
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2067
Practice Address - Country:US
Practice Address - Phone:302-738-5300
Practice Address - Fax:302-731-4822
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPENDING174400000X
DEC1-0011248207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK729-R074Medicare PIN
DE410769ZAVTMedicare PIN