Provider Demographics
NPI:1083603062
Name:KHAN, IQBAL AHMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:IQBAL
Middle Name:AHMAD
Last Name:KHAN
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 1:30 ED PREATE DR STE 109
Mailing Address - Street 2:
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1755
Mailing Address - Country:US
Mailing Address - Phone:570-678-2588
Mailing Address - Fax:866-259-6004
Practice Address - Street 1:30 ED PREATE DR # 109
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1755
Practice Address - Country:US
Practice Address - Phone:570-678-2588
Practice Address - Fax:866-259-6004
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA052377L2084N0400X
PAMD052377L2084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010856870001Medicaid
F91128Medicare UPIN
PA1010856870001Medicaid