Provider Demographics
NPI:1023524618
Name:FAROOQ, KANWAL (MD)
Entity type:Individual
Prefix:
First Name:KANWAL
Middle Name:
Last Name:FAROOQ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KANWAL
Other - Middle Name:
Other - Last Name:SHAHID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:101 NICOLLS RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8160
Practice Address - Country:US
Practice Address - Phone:631-444-1665
Practice Address - Fax:631-865-1180
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY300329-01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program