Provider Demographics
NPI:1609824259
Name:KSAIBATI, AHMAD G (MD)
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:G
Last Name:KSAIBATI
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:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-0048
Mailing Address - Country:US
Mailing Address - Phone:813-685-4205
Mailing Address - Fax:
Practice Address - Street 1:5504 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-4270
Practice Address - Country:US
Practice Address - Phone:813-948-5400
Practice Address - Fax:813-907-2073
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44509207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036020100Medicaid
D54100Medicare UPIN
FL30721Medicare ID - Type Unspecified