Provider Demographics
NPI:1184619835
Name:AMIN, IQBAL (MD)
Entity type:Individual
Prefix:DR
First Name:IQBAL
Middle Name:
Last Name:AMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:318-525-1866
Mailing Address - Fax:314-525-1868
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:318-525-1866
Practice Address - Fax:314-525-1868
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO110953207RG0300X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204876908Medicaid
MOH07942Medicare UPIN
MO990401390Medicare PIN
MO007013512Medicare ID - Type Unspecified