Provider Demographics
NPI:1164598512
Name:CHOUDHRY, BABAR MURTAZA (MD/OWNER)
Entity Type:Individual
Prefix:
First Name:BABAR
Middle Name:MURTAZA
Last Name:CHOUDHRY
Suffix:
Gender:M
Credentials:MD/OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1388
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0379
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:420 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3625
Practice Address - Country:US
Practice Address - Phone:570-621-5500
Practice Address - Fax:570-621-5077
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066893L2084P0800X, 2084P0805X, 314000000X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018148730009Medicaid
PA0018148730009Medicaid
H23314Medicare UPIN