Healthcare Provider Details

I. General information

NPI: 1730372228
Provider Name (Legal Business Name): LUBNA IZZATHULLAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N PARKE ST
ABERDEEN MD
21001-2428
US

IV. Provider business mailing address

17177 N LAUREL PARK DR STE 131
LIVONIA MI
48152-3952
US

V. Phone/Fax

Practice location:
  • Phone: 443-625-1600
  • Fax: 443-625-1520
Mailing address:
  • Phone: 410-308-4605
  • Fax: 443-625-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD0066085
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0066085
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier298521702
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: