Healthcare Provider Details

I. General information

NPI: 1568441855
Provider Name (Legal Business Name): KHONDKER ISLAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E LAKE SHORE DR
DECATUR IL
62521-3809
US

IV. Provider business mailing address

1730 E LAKE SHORE DR
DECATUR IL
62521-3809
US

V. Phone/Fax

Practice location:
  • Phone: 217-329-1000
  • Fax:
Mailing address:
  • Phone: 217-329-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number24098
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036102111
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number069489
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: