Healthcare Provider Details

I. General information

NPI: 1295765550
Provider Name (Legal Business Name): IKRAM ULHAQ QURESHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 S WEEKS ST
BONIFAY FL
32425-3047
US

IV. Provider business mailing address

812 S WEEKS ST
BONIFAY FL
32425-3047
US

V. Phone/Fax

Practice location:
  • Phone: 850-547-4771
  • Fax: 850-547-3171
Mailing address:
  • Phone: 850-547-4771
  • Fax: 850-547-3171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME23207
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: