Provider Demographics
NPI:1578558219
Name:ALI, AKBAR (MD)
Entity Type:Individual
Prefix:
First Name:AKBAR
Middle Name:
Last Name:ALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:AKBAR
Other - Middle Name:
Other - Last Name:ALI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:C/O MSO ADMINISTRATION
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-624-4777
Mailing Address - Fax:575-626-8711
Practice Address - Street 1:601 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5224
Practice Address - Country:US
Practice Address - Phone:575-627-0535
Practice Address - Fax:575-627-5590
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0029208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16376013Medicaid
WA8289639Medicaid
NM343611002Medicare PIN
WA8289639Medicaid
G85345Medicare UPIN