Basic Information
| Provider Information | |||||||||
| NPI: | 1265558555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANKOLKAR | ||||||||
| FirstName: | IRFAN | ||||||||
| MiddleName: | MUNIRUDDIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 17TH STREET | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612010000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097795000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2701 17TH ST | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612015351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097795000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-119417 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 95149 | 01 | IA | WELLMARK | OTHER | 99854 | 01 | IA | WELLMARK | OTHER | 036-119417 | 05 | IL | MEDICAID | P00616052 | 01 | IL | RR MEDICARE | OTHER |