Individual
DR. MOHAMMED SOUBHI NIZAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1055 N 500 W STE 205, PROVO, UT 84604-3305
(801) 429-8095
(801) 354-8265
Mailing address
1055 N 500 W, ATTN: CREDENTIALING, PROVO, UT 84604-3305
(801) 354-8225
(801) 418-0941
Taxonomy
Speciality
Code
Description
License number
State
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
Primary
6955621-1205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000705030
ANTHEM PROVIDER NUMBER
IN
05
—
201013750
—
IN
Enumeration date
07/28/2008
Last updated
11/27/2023
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