Provider Demographics
NPI:1073680245
Name:ISMAIL, AHMAD TARIQ (MD)
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:TARIQ
Last Name:ISMAIL
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 1:110 EAST BYRD AVE
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425
Mailing Address - Country:US
Mailing Address - Phone:850-547-4799
Mailing Address - Fax:850-547-2305
Practice Address - Street 1:110 EAST BYRD AVE
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425
Practice Address - Country:US
Practice Address - Phone:850-547-4799
Practice Address - Fax:850-547-2305
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46198OtherBCBS
FL043432900Medicaid
FL660056500Medicaid
D54980Medicare UPIN
FL043432900Medicaid