Healthcare Provider Details

I. General information

NPI: 1720067168
Provider Name (Legal Business Name): IBRAIZ IQBAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 HARDIN LN SUITE B
SOMERSET KY
42503-3800
US

IV. Provider business mailing address

104 HARDIN LN SUITE B
SOMERSET KY
42503-3800
US

V. Phone/Fax

Practice location:
  • Phone: 606-677-1112
  • Fax: 606-679-1341
Mailing address:
  • Phone: 606-677-1112
  • Fax: 606-679-1341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number38636
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: