Provider Demographics
NPI:1710208913
Name:ISLAM, EBTESAM (MD, PHD)
Entity type:Individual
Prefix:
First Name:EBTESAM
Middle Name:
Last Name:ISLAM
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 4TH ST
Mailing Address - Street 2:MS 9410
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-9410
Mailing Address - Country:US
Mailing Address - Phone:806-743-3155
Mailing Address - Fax:806-743-3143
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:MS 9410
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-9410
Practice Address - Country:US
Practice Address - Phone:806-743-3155
Practice Address - Fax:806-743-3143
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR0253207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363703501Medicaid