Provider Demographics
NPI:1770606063
Name:ISLAM, MAHJABEEN (MD)
Entity type:Individual
Prefix:DR
First Name:MAHJABEEN
Middle Name:
Last Name:ISLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MAHJABEEN
Other - Middle Name:
Other - Last Name:ISLAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:959 ILLINOIS AVE STE E
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1744
Mailing Address - Country:US
Mailing Address - Phone:419-872-0500
Mailing Address - Fax:419-874-4650
Practice Address - Street 1:959 ILLINOIS AVE STE E
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1744
Practice Address - Country:US
Practice Address - Phone:419-872-0500
Practice Address - Fax:419-874-4650
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH053406207QA0401X
OH35.053406207Q00000X
OH207QA0401X207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0696591Medicaid
OH0594773Medicare ID - Type Unspecified
OH0696591Medicaid