Provider Demographics
NPI:1669465381
Name:NAKKOUL, ANWAR (MD)
Entity type:Individual
Prefix:
First Name:ANWAR
Middle Name:
Last Name:NAKKOUL
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 1:1023 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17921-1204
Mailing Address - Country:US
Mailing Address - Phone:570-875-3665
Mailing Address - Fax:570-875-2012
Practice Address - Street 1:1023 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:PA
Practice Address - Zip Code:17921-1204
Practice Address - Country:US
Practice Address - Phone:570-875-3665
Practice Address - Fax:570-875-2012
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059146L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG30491Medicare UPIN
PA43303Medicare ID - Type Unspecified