Provider Demographics
NPI:1538191929
Name:IQBAL, NUSRUM (MD)
Entity type:Individual
Prefix:
First Name:NUSRUM
Middle Name:
Last Name:IQBAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 COLONIA DE SALUD STE 200C
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2486
Mailing Address - Country:US
Mailing Address - Phone:520-335-2800
Mailing Address - Fax:520-335-2804
Practice Address - Street 1:75 COLONIA DE SALUD
Practice Address - Street 2:SUITE 200C
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2487
Practice Address - Country:US
Practice Address - Phone:520-335-2800
Practice Address - Fax:520-335-2804
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ836033Medicaid
AZDR2642OtherMEDICARE PTAN RR GROUP
AZZ140497OtherMEDICARE PTAN BUSINESS
AZP00915869OtherMEDICARE PTAN RR PROVIDER
AZZ140498OtherMEDICARE PTAN INDIVIDUAL
AZZ144296OtherMEDICARE PTAN FOR OROVALLEY, AZ
I01247Medicare UPIN