Provider Demographics
NPI:1083714117
Name:QAYYUM, TAHIR M (MD)
Entity Type:Individual
Prefix:
First Name:TAHIR
Middle Name:M
Last Name:QAYYUM
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 1:540 DURHAM ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5013
Mailing Address - Country:US
Mailing Address - Phone:318-283-2200
Mailing Address - Fax:318-283-1200
Practice Address - Street 1:540 DURHAM ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5013
Practice Address - Country:US
Practice Address - Phone:318-283-2200
Practice Address - Fax:318-283-1200
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10850R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1680061Medicaid
LA080144244OtherRAILROAD MEDICARE
LA5Y192Medicare ID - Type Unspecified
LA080144244OtherRAILROAD MEDICARE