Provider Demographics
NPI:1184914525
Name:KASAM, IQBAL ISMAIL (MD)
Entity type:Individual
Prefix:DR
First Name:IQBAL
Middle Name:ISMAIL
Last Name:KASAM
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 1:11222 RAVENNA LN
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-4171
Mailing Address - Country:US
Mailing Address - Phone:818-621-3919
Mailing Address - Fax:
Practice Address - Street 1:39115 TRADE CENTER DR # 130
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3649
Practice Address - Country:US
Practice Address - Phone:661-273-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109426207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine