Provider Demographics
NPI:1164693537
Name:SYED WAJAHAT ALI MD PA
Entity Type:Organization
Organization Name:SYED WAJAHAT ALI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:WAJAHAT
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-797-9677
Mailing Address - Street 1:14540 CORTEZ BLVD
Mailing Address - Street 2:SUITE # 116
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6056
Mailing Address - Country:US
Mailing Address - Phone:352-797-9677
Mailing Address - Fax:352-797-9857
Practice Address - Street 1:14540 CORTEZ BLVD
Practice Address - Street 2:SUITE # 116
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6056
Practice Address - Country:US
Practice Address - Phone:352-797-9677
Practice Address - Fax:352-797-9857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3744Medicare PIN
FLG53874Medicare UPIN