Healthcare Provider Details

I. General information

NPI: 1457181851
Provider Name (Legal Business Name): IHTESHAM SHAFIQ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 JEFFERSON ST
LAUREL MS
39440-4355
US

IV. Provider business mailing address

920 MADISON AVE STE 531920
MEMPHIS TN
38103-3438
US

V. Phone/Fax

Practice location:
  • Phone: 276-269-8148
  • Fax:
Mailing address:
  • Phone: 901-448-2510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberSHAF-JN2CME
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: