Provider Demographics
NPI:1205832151
Name:JAVID, AHMAD
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:JAVID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAVID
Other - Middle Name:
Other - Last Name:AHMAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:85 SOUTH WEST STREET
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077
Mailing Address - Country:US
Mailing Address - Phone:607-753-3797
Mailing Address - Fax:
Practice Address - Street 1:24 GROTON AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2014
Practice Address - Country:US
Practice Address - Phone:607-753-3774
Practice Address - Fax:607-753-3947
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5166489208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01669089Medicaid
NYH64076Medicare UPIN
NY01669089Medicaid