MEDICARE: IMTIAZ ISMAIL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician	2021022845	MO
2	207R00000X	Internal Medicine Physician	036138972	IL
3	208M00000X	Hospitalist Physician	036138972	IL

General Provider Information

NPI Number	:	1114369170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMTIAZ ISMAIL MD

Provider Business Mailing Address
First Line	:	100 MEDICAL DR
Second Line	:
City	:	HANNIBAL
State	:	MO
Zip	:	63401-6877
Country	:	US
Telephone Number	:	331-221-6377
Fax Number	:	331-221-2701

Provider Business Practice Location Address
First Line	:	113 AIRPORT RD STE 301
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-2198
Country	:	US
Telephone Number	:	903-438-8330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2013
Last Update Date	:	06/15/2026

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