Provider Demographics
NPI:1740200153
Name:WALIA, IQBAL (MD)
Entity Type:Individual
Prefix:
First Name:IQBAL
Middle Name:
Last Name:WALIA
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 281562
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1562
Mailing Address - Country:US
Mailing Address - Phone:904-482-1070
Mailing Address - Fax:904-482-1077
Practice Address - Street 1:2600 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:NY
Practice Address - Zip Code:14108-1026
Practice Address - Country:US
Practice Address - Phone:716-778-5071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131516-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01590707/04Medicaid
NY000523881002OtherBLUE SHIELD
NYE83773Medicare UPIN
NY01590707/04Medicaid