Provider Demographics
NPI:1568441855
Name:ISLAM, KHONDKER (MD)
Entity Type:Individual
Prefix:
First Name:KHONDKER
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 1:1730 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3809
Mailing Address - Country:US
Mailing Address - Phone:217-329-1000
Mailing Address - Fax:
Practice Address - Street 1:1730 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3809
Practice Address - Country:US
Practice Address - Phone:217-329-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069489207RG0100X
IL36102111207RG0100X
MS24098207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36102111Medicaid
GA003133230AMedicaid
H13348Medicare UPIN
IL578740Medicare ID - Type Unspecified