Provider Demographics
NPI:1407993157
Name:AHMADI, ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:AHMADI
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 1:3902 NORTHSIDE DR
Mailing Address - Street 2:SUITE A4
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2459
Mailing Address - Country:US
Mailing Address - Phone:478-474-8774
Mailing Address - Fax:478-474-8734
Practice Address - Street 1:3902 NORTHSIDE DR
Practice Address - Street 2:SUITE A4
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2459
Practice Address - Country:US
Practice Address - Phone:478-474-8774
Practice Address - Fax:478-474-8734
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA468242084P0800X
GA0468242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00832378CMedicaid
GA00832378CMedicaid