Provider Demographics
NPI:1699768911
Name:AHMAD, MAQBOOL (MD)
Entity type:Individual
Prefix:DR
First Name:MAQBOOL
Middle Name:
Last Name:AHMAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W DEYOUNG ST
Mailing Address - Street 2:P.O. BOX 1178
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:608-993-5686
Mailing Address - Fax:618-997-5505
Practice Address - Street 1:1200 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4437
Practice Address - Country:US
Practice Address - Phone:608-993-5686
Practice Address - Fax:618-997-6250
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-051996207W00000X
MO35374207W00000X, 207WX0107X
IL036051996207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0814870010OtherMEDICARE NSC NUMBER
MO0814870013OtherMEDICARE NSC NUMBER
MO133794OtherANTHEM BLUE CROSS BLUE SHIELD OF MO
236683OtherHARMONY HEALTH PLAN
MOP00418684, CI6575OtherMEDICARE RAILROAD
034431OtherHEALTH ALLIANCE
IL0814870001OtherMEDICARE NSC NUMBER
100033OtherHEALTHLINK
IL791580195OtherMEDICARE RAILROAD
IL0814870008OtherMEDICARE NSC NUMBER
MO0814870002OtherMEDICARE NSC NUMBER
IL0814870023OtherMEDICARE NSC NUMBER
IL0814870030OtherMEDICARE NSC NUMBER
IL0814870022OtherMEDICARE NSC NUMBER
IL0814870027OtherMEDICARE NSC NUMBER
IL0814870028OtherMEDICARE NSC NUMBER
IL0814870007OtherMEDICARE NSC NUMBER
MO203169800Medicaid
IL036051996Medicaid
IL0814870031OtherMEDICARE NSC NUMBER
IL0814870027OtherMEDICARE NSC NUMBER
IL0814870028OtherMEDICARE NSC NUMBER
MO000004665Medicare PIN