Basic Information
| Provider Information | |||||||||
| NPI: | 1710269824 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AQIB SULTAN MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960428 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856497070 | ||||||||
| FaxNumber: | 4053419217 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL CENTER DR | ||||||||
| Address2: | OCHSNER MED CTR - NORTHSHORE | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704615520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856497070 | ||||||||
| FaxNumber: | 4053419217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2011 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | SULTAN | ||||||||
| AuthorizedOfficialFirstName: | AQIB | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9856497070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04388245 | 05 | MS | MEDICAID | 2168754 | 05 | LA | MEDICAID | DS1176 | 01 | LA | RAILROAD MCARE | OTHER |