Provider Demographics
NPI:1417055526
Name:AHMAD, MOHAMMAD IMTIAZ (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:IMTIAZ
Last Name:AHMAD
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 1:2702 NORTH 3RD STREET
Mailing Address - Street 2:SUITE 4020
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4608
Mailing Address - Country:US
Mailing Address - Phone:602-323-3344
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:635 EAST BASELINE ROAD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-5019
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38013207V00000X
AZ13260207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20503Medicaid
CA00A380130Medicaid
AZ205303Medicaid
AZ20503Medicaid
Z130382Medicare PIN
AZ205303Medicaid
CA00A380130Medicaid
CAD36486Medicare ID - Type Unspecified