Provider Demographics
NPI:1710907613
Name:QAISAR J QAYYUM MD, PC
Entity Type:Organization
Organization Name:QAISAR J QAYYUM MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:QAISAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:QAYYUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-562-8715
Mailing Address - Street 1:PO BOX 31195
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003
Mailing Address - Country:US
Mailing Address - Phone:405-562-8715
Mailing Address - Fax:
Practice Address - Street 1:13974 S BROADWAY
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-8144
Practice Address - Country:US
Practice Address - Phone:405-562-8715
Practice Address - Fax:405-562-8717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21912207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH34941Medicare UPIN
300522245Medicare PIN