Healthcare Provider Details

I. General information

NPI: 1174001606
Provider Name (Legal Business Name): HABIBA TAHIRA HUSSAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 E 19TH ST STE 200
TULSA OK
74104-5419
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 918-748-8381
  • Fax:
Mailing address:
  • Phone: 309-655-2730
  • Fax: 309-655-3297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125072191
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number42427
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: