Provider Demographics
NPI:1619965258
Name:IQBAL, SHAHID (MD)
Entity Type:Individual
Prefix:
First Name:SHAHID
Middle Name:
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 1:3319 FOREST SHADOWS DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2801
Mailing Address - Country:US
Mailing Address - Phone:423-892-0680
Mailing Address - Fax:423-821-1177
Practice Address - Street 1:3812 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37409
Practice Address - Country:US
Practice Address - Phone:423-821-1177
Practice Address - Fax:423-821-1188
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA53071207Q00000X
TN37677207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3337823Medicaid
TN3337823Medicaid
TN3337823Medicare ID - Type Unspecified