Provider Demographics
NPI:1891703161
Name:KIBLAWI, ISAM S (MD)
Entity Type:Individual
Prefix:DR
First Name:ISAM
Middle Name:S
Last Name:KIBLAWI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2540 N GALLOWAY AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6306
Mailing Address - Country:US
Mailing Address - Phone:972-686-1777
Mailing Address - Fax:972-686-7330
Practice Address - Street 1:2540 N GALLOWAY AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6306
Practice Address - Country:US
Practice Address - Phone:972-686-1777
Practice Address - Fax:972-686-7330
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF-5605208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE80301Medicare UPIN