Provider Demographics
NPI:1114331337
Name:AHMADINEJAD, TINA (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:
Last Name:AHMADINEJAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 N DELAWARE AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-4338
Mailing Address - Country:US
Mailing Address - Phone:267-463-5800
Mailing Address - Fax:215-586-6038
Practice Address - Street 1:1080 N DELAWARE AVE STE 800
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-4338
Practice Address - Country:US
Practice Address - Phone:267-463-5800
Practice Address - Fax:215-586-6038
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT207183390200000X
PAMD460436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program