Provider Demographics
NPI:1376173609
Name:ALI, TARIK A (PROVIDER)
Entity Type:Individual
Prefix:
First Name:TARIK
Middle Name:A
Last Name:ALI
Suffix:
Gender:M
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WILCOX ST
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1250
Mailing Address - Country:US
Mailing Address - Phone:860-328-9450
Mailing Address - Fax:
Practice Address - Street 1:12 WILCOX ST
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-1250
Practice Address - Country:US
Practice Address - Phone:860-328-9450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver