Provider Demographics
NPI:1306842869
Name:ALI, SYED WASIM (MD)
Entity Type:Individual
Prefix:DR
First Name:SYED
Middle Name:WASIM
Last Name:ALI
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:P O BOX 1960
Mailing Address - Street 2:US HIGHWAY 1 SOUTH STE 20
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-824-5386
Mailing Address - Fax:904-824-5387
Practice Address - Street 1:236 SOUTHPARK CIRCLE EAST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-824-5386
Practice Address - Fax:904-824-5387
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068402207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28877OtherBLUE CROSS BLUE SHEILD ID
FL593463106OtherTAX IDENTIFICATION NUMBER
FL250283600Medicaid
FL5438521OtherAETNA PROVIDER #
FL250283600Medicaid
FL5438521OtherAETNA PROVIDER #