Provider Demographics
NPI:1518132489
Name:MAHMUD, GIBRAN HAMID (MD)
Entity Type:Individual
Prefix:
First Name:GIBRAN
Middle Name:HAMID
Last Name:MAHMUD
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 1:1052 M L KING DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3002
Mailing Address - Country:US
Mailing Address - Phone:618-436-5410
Mailing Address - Fax:618-436-8063
Practice Address - Street 1:1052 M L KING DR
Practice Address - Street 2:SUITE 2
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3002
Practice Address - Country:US
Practice Address - Phone:618-436-5410
Practice Address - Fax:618-436-8063
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011020105207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1518132489Medicaid
IL1518132489Medicaid
MO1518132489Medicaid