Provider Demographics
NPI:1336133420
Name:AHMED, MOINUDDIN (MD)
Entity Type:Individual
Prefix:
First Name:MOINUDDIN
Middle Name:
Last Name:AHMED
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 1:123 PIKE ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-1824
Mailing Address - Country:US
Mailing Address - Phone:845-856-2244
Mailing Address - Fax:845-856-1166
Practice Address - Street 1:123 PIKE ST
Practice Address - Street 2:SUITE 207
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1824
Practice Address - Country:US
Practice Address - Phone:845-856-2244
Practice Address - Fax:845-856-1166
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60211958207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02062875Medicaid
G99927Medicare UPIN
7V5661Medicare ID - Type Unspecified