Provider Demographics
NPI:1508038597
Name:ATHAR, SYED AHMED (MD)
Entity Type:Individual
Prefix:DR
First Name:SYED
Middle Name:AHMED
Last Name:ATHAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AHMED
Other - Middle Name:
Other - Last Name:ATHAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11201 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92357-1000
Mailing Address - Country:US
Mailing Address - Phone:909-583-6097
Mailing Address - Fax:909-777-3273
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-583-6097
Practice Address - Fax:909-777-3273
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108169207RC0000X, 207RI0011X
IN01065071A207RC0000X
ORMD192265207RI0011X
ARE-8144207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200244001Medicaid
IN940550I8Medicare PIN
AR307673YJS9Medicare PIN