Provider Demographics
NPI:1659355949
Name:ULLAH, MOHAMMAD IFTEKHAR (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:IFTEKHAR
Last Name:ULLAH
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 1:2500 N STATE ST
Mailing Address - Street 2:GENERAL MEDICINE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5660
Mailing Address - Fax:601-984-6870
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE DIVISION OF GENERAL INTERNAL MED
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5660
Practice Address - Fax:601-984-6870
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20270207RS0012X
MN46137207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN131016Medicaid
MN1907892OtherARAZ
FM8315OtherAVERA
MN04-06055OtherMEDICA
MNA068OtherCHAMPUS
MNMH9041035166OtherPREFERRED ONE
MN099K8ULOtherBLUE CROSS
MN099K8ULMedicaid
MN644957300Medicaid
MS06022776Medicaid
MNHP39736OtherHEALTH PARTNERS
MSP00628051OtherRAILROAD
IA566034Medicaid
MNA068OtherCHAMPUS
MN1907892OtherARAZ
MN110009900Medicare UPIN
MS06022776Medicaid
MS302I117081Medicare PIN
MN1907892OtherARAZ
MS06022776Medicaid