Healthcare Provider Details

I. General information

NPI: 1760468995
Provider Name (Legal Business Name): FAUZIA IQBAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 E 10TH ST
ROLLA MO
65401-3648
US

IV. Provider business mailing address

11660 GREENWOOD CT
ROLLA MO
65401-7310
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-7551
  • Fax: 573-364-4898
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number111162
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: