Provider Demographics
NPI:1003839655
Name:AHMED, SHAMIM (MD)
Entity Type:Individual
Prefix:
First Name:SHAMIM
Middle Name:
Last Name:AHMED
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 1:10 BARRYPARK CT
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1502
Mailing Address - Country:US
Mailing Address - Phone:718-205-6561
Mailing Address - Fax:718-205-4815
Practice Address - Street 1:6413 BROADWAY
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2336
Practice Address - Country:US
Practice Address - Phone:718-205-6561
Practice Address - Fax:718-205-4815
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237709207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02322732Medicaid
NY080AQ1Medicare ID - Type Unspecified
NY02322732Medicaid