Provider Demographics
NPI:1417008426
Name:AHMADI, EBRAHIM (MD)
Entity Type:Individual
Prefix:DR
First Name:EBRAHIM
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 1:38143 MARTHA AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-3800
Mailing Address - Country:US
Mailing Address - Phone:510-791-2002
Mailing Address - Fax:
Practice Address - Street 1:38143 MARTHA AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3800
Practice Address - Country:US
Practice Address - Phone:510-791-2002
Practice Address - Fax:510-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA050313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A503131Medicaid
CA00A503131Medicaid
CAF91679Medicare UPIN