Provider Demographics
NPI:1447211305
Name:IQBAL, MOHAMMAD JAVAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:JAVAD
Last Name:IQBAL
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:PO BOX 2636
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2636
Mailing Address - Country:US
Mailing Address - Phone:270-769-3631
Mailing Address - Fax:270-769-3996
Practice Address - Street 1:1230 WOODLAND DRIVE SUITE 110
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701
Practice Address - Country:US
Practice Address - Phone:270-769-3631
Practice Address - Fax:270-769-3996
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18016208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
50000419OtherPASSPORT
000000045927OtherANTHEM
KY64180169Medicaid
KY1050901Medicare ID - Type Unspecified
50000419OtherPASSPORT
KY1050901Medicare PIN