Provider Demographics
NPI:1255688271
Name:OTHMAN, AHMAD H (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMAD
Middle Name:H
Last Name:OTHMAN
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 1:2508 FAIRWAY TER
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2734
Mailing Address - Country:US
Mailing Address - Phone:312-813-6958
Mailing Address - Fax:
Practice Address - Street 1:233 FAIRWAY TER N STE B
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3060
Practice Address - Country:US
Practice Address - Phone:575-762-7779
Practice Address - Fax:575-762-3526
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2018-0173208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12875279Medicaid