Provider Demographics
NPI:1659722361
Name:FARAG, AHMED ALY (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMED
Middle Name:ALY
Last Name:FARAG
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 1:2401 STATE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3942
Mailing Address - Country:US
Mailing Address - Phone:850-481-6124
Mailing Address - Fax:502-385-6561
Practice Address - Street 1:2401 STATE AVE STE 100
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3942
Practice Address - Country:US
Practice Address - Phone:502-262-5980
Practice Address - Fax:502-385-6561
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYIP15182085R0202X
SCLL39706208600000X
FLME1583522085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP0908OtherMEDICARE
FL115773100Medicaid