Provider Demographics
NPI:1366481905
Name:AHMAD, MASOOD (MD)
Entity Type:Individual
Prefix:
First Name:MASOOD
Middle Name:
Last Name:AHMAD
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 1:6565 S YALE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8327
Mailing Address - Country:US
Mailing Address - Phone:918-392-5400
Mailing Address - Fax:918-392-5399
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4730
Practice Address - Fax:517-205-4701
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010737232084P0800X
TN356922084P0800X
TN0000035692208D00000X
OK288642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3816082Medicaid
OK200435250AMedicaid
MI1366481905Medicaid