Provider Demographics
NPI:1619986155
Name:AHMED, IMTIAZ (MD)
Entity Type:Individual
Prefix:MR
First Name:IMTIAZ
Middle Name:
Last Name:AHMED
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 1:211 NORTHPARKE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1117
Mailing Address - Country:US
Mailing Address - Phone:937-390-1700
Mailing Address - Fax:937-390-2471
Practice Address - Street 1:211 NORTHPARKE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1117
Practice Address - Country:US
Practice Address - Phone:937-390-1700
Practice Address - Fax:937-390-2471
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0828779Medicaid
OH0828779Medicaid
OHAH4250412Medicare PIN
OH0696082Medicare PIN
OHAH4250411Medicare PIN