Basic Information
| Provider Information | |||||||||
| NPI: | 1598755993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IQBAL | ||||||||
| FirstName: | KHALID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 E WARNER RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106136 | ||||||||
| FaxNumber: | 4806106189 | ||||||||
| Practice Location | |||||||||
| Address1: | 2431 CIRCLEWOOD RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303451949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047610819 | ||||||||
| FaxNumber: | 4047682336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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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 | 174400000X | 055785 | GA | N | Other Service Providers | Specialist | 207RN0300X | 55785 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 577858670A | 05 | GA | MEDICAID |