Provider Demographics
NPI:1104825090
Name:KIZILBASH, ALI M (MD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:M
Last Name:KIZILBASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1110 COTTONWOOD LN
Mailing Address - Street 2:SUITE 105
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6117
Mailing Address - Country:US
Mailing Address - Phone:972-607-2525
Mailing Address - Fax:972-252-8837
Practice Address - Street 1:1110 COTTONWOOD LN
Practice Address - Street 2:SUITE 105
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6117
Practice Address - Country:US
Practice Address - Phone:972-607-2525
Practice Address - Fax:972-252-8837
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK0095207R00000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105298707Medicaid
TX105298706Medicaid
TX105298708Medicaid
TX105298708Medicaid
TXTXB113271Medicare PIN
TXTXB113262Medicare PIN
TXP00927076Medicare PIN
TX105298706Medicaid