Provider Demographics
NPI:1174577035
Name:ISLAM, RAQUIBUL (MD)
Entity type:Individual
Prefix:
First Name:RAQUIBUL
Middle Name:
Last Name:ISLAM
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 1:2600 W 9TH ST
Mailing Address - Street 2:2 NORTH
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-2040
Mailing Address - Country:US
Mailing Address - Phone:610-485-3800
Mailing Address - Fax:610-485-4221
Practice Address - Street 1:125 E 9TH ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-6019
Practice Address - Country:US
Practice Address - Phone:671-872-6131
Practice Address - Fax:610-872-5128
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062423L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016718790005Medicaid
PAG63131Medicare UPIN
PA005165Medicare ID - Type Unspecified