Provider Demographics
NPI:1376776153
Name:AL-MUFTI, FAWAZ AHMED SAMI (MD)
Entity Type:Individual
Prefix:DR
First Name:FAWAZ
Middle Name:AHMED SAMI
Last Name:AL-MUFTI
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 1:710 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3726
Mailing Address - Country:US
Mailing Address - Phone:212-305-7236
Mailing Address - Fax:212-305-2792
Practice Address - Street 1:100 WOODS RD # A
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2704402084N0400X
MA241152208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03782198Medicaid
NY270440OtherNYS LICENSE
NYA400191607OtherMEDICARE