Provider Demographics
NPI:1720025448
Name:QAYYUM, QAISAR (MD)
Entity Type:Individual
Prefix:DR
First Name:QAISAR
Middle Name:
Last Name:QAYYUM
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:PO BOX 31195
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-0020
Mailing Address - Country:US
Mailing Address - Phone:405-562-8715
Mailing Address - Fax:405-562-8717
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
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21912207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100063090AMedicaid
300522245Medicare PIN