Provider Demographics
NPI:1043599509
Name:MAMILLY, AHMED (MD)
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:
Last Name:MAMILLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MEDICAL CENTER DR STE 3A
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8124
Mailing Address - Country:US
Mailing Address - Phone:318-484-3899
Mailing Address - Fax:318-484-3887
Practice Address - Street 1:501 MEDICAL CENTER DR STE 3A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8124
Practice Address - Country:US
Practice Address - Phone:318-484-3899
Practice Address - Fax:318-484-3887
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA207399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2157566Medicaid