Provider Demographics
NPI:1114192671
Name:SHAH, IQTIDAR UL-HASSAN (MD)
Entity Type:Individual
Prefix:
First Name:IQTIDAR
Middle Name:UL-HASSAN
Last Name:SHAH
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 1:4004 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-7854
Mailing Address - Country:US
Mailing Address - Phone:903-455-4485
Mailing Address - Fax:903-455-1944
Practice Address - Street 1:4004 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7854
Practice Address - Country:US
Practice Address - Phone:903-455-4485
Practice Address - Fax:903-455-1944
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0365208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138053707Medicaid
TX138053707Medicaid
TXD69073Medicare UPIN