Provider Demographics
NPI:1932374469
Name:HABIB, IHTASHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:IHTASHAM
Middle Name:
Last Name:HABIB
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 1:4927 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4813
Mailing Address - Country:US
Mailing Address - Phone:813-480-2892
Mailing Address - Fax:813-428-5884
Practice Address - Street 1:4927 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4813
Practice Address - Country:US
Practice Address - Phone:813-480-2892
Practice Address - Fax:813-428-5884
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37876208M00000X
FLME106984208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15915005Medicare PIN
IA0203123Medicaid
I15915005Medicare PIN