Provider Demographics
NPI:1376924308
Name:TARIQ, ALI (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:TARIQ
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 1:11375 CORTEZ BOULEVARD, STATE ROAD 50, OAK HILL HOSPITA
Mailing Address - Street 2:SUPPLY GME ATTN: MELISSA TAMMARO, PROGRAM COORDINATOR
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613
Mailing Address - Country:US
Mailing Address - Phone:352-592-2753
Mailing Address - Fax:352-597-6173
Practice Address - Street 1:8383 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514
Practice Address - Country:US
Practice Address - Phone:850-494-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135065207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty