Provider Demographics
NPI:1265626790
Name:SOULTANOVA, IZOUMROUD OSMANOVNA (MD, PHD)
Entity type:Individual
Prefix:
First Name:IZOUMROUD
Middle Name:OSMANOVNA
Last Name:SOULTANOVA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11912 KANIS RD STE F2
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3771
Mailing Address - Country:US
Mailing Address - Phone:501-227-8020
Mailing Address - Fax:
Practice Address - Street 1:11912 KANIS RD STE F2
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3771
Practice Address - Country:US
Practice Address - Phone:501-227-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183018001Medicaid
AR183018001Medicaid