Provider Demographics
NPI:1720067168
Name:IQBAL, IBRAIZ (MD)
Entity Type:Individual
Prefix:
First Name:IBRAIZ
Middle Name:
Last Name:IQBAL
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 1:104 HARDIN LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3800
Mailing Address - Country:US
Mailing Address - Phone:606-677-1112
Mailing Address - Fax:606-679-1341
Practice Address - Street 1:104 HARDIN LN
Practice Address - Street 2:SUITE B
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3800
Practice Address - Country:US
Practice Address - Phone:606-677-1112
Practice Address - Fax:606-679-1341
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38636207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00147774OtherPALMETTO GBA
KY000000336184OtherANTHEM BCBS
KY000000336184OtherBCBS
KY64082605Medicaid
KY000000336184OtherANTHEM BCBS
KYP00147774OtherPALMETTO GBA
KYP00147774OtherPALMETTO GBA
KY0926201Medicare ID - Type Unspecified