Provider Demographics
NPI:1114369170
Name:ISMAIL, IMTIAZ (MD)
Entity type:Individual
Prefix:
First Name:IMTIAZ
Middle Name:
Last Name:ISMAIL
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6877
Mailing Address - Country:US
Mailing Address - Phone:331-221-6377
Mailing Address - Fax:331-221-2701
Practice Address - Street 1:113 AIRPORT RD STE 301
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2198
Practice Address - Country:US
Practice Address - Phone:903-438-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138972207R00000X, 208M00000X
MO2021022845207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty