Provider Demographics
NPI:1497702567
Name:AHMADANI, IKRAMULLAH (MD)
Entity Type:Individual
Prefix:
First Name:IKRAMULLAH
Middle Name:
Last Name:AHMADANI
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 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2619
Mailing Address - Country:US
Mailing Address - Phone:803-758-2600
Mailing Address - Fax:803-253-8896
Practice Address - Street 1:1818 HENDERSON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2619
Practice Address - Country:US
Practice Address - Phone:803-758-2600
Practice Address - Fax:803-253-8896
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052675207R00000X, 208D00000X
SC19633207P00000X, 207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA520862907BMedicaid
GA520862907EMedicaid
GA520862907FMedicaid
GA520862907CMedicaid
GA520862907GMedicaid
GA581762046OtherGROUP TAX I.D.- GA CLINIC
GA520862907EMedicaid
GA520862907BMedicaid