Provider Demographics
NPI:1326302043
Name:ELAZAB, AHMED M (BS)
Entity Type:Individual
Prefix:MR
First Name:AHMED
Middle Name:M
Last Name:ELAZAB
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18902 64TH AVE APT 7B
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3828
Mailing Address - Country:US
Mailing Address - Phone:212-810-9867
Mailing Address - Fax:
Practice Address - Street 1:18902 64TH AVE APT 7B
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-3828
Practice Address - Country:US
Practice Address - Phone:212-810-9867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026963-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist