Healthcare Provider Details

I. General information

NPI: 1164598512
Provider Name (Legal Business Name): BABAR MURTAZA CHOUDHRY MD/OWNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S JACKSON ST
POTTSVILLE PA
17901-3625
US

IV. Provider business mailing address

PO BOX 1388
KINGSTON PA
18704-0379
US

V. Phone/Fax

Practice location:
  • Phone: 570-621-5500
  • Fax: 570-621-5077
Mailing address:
  • Phone: 570-288-8881
  • Fax: 570-288-8065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD066893L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberMD066893L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: