Provider Demographics
NPI:1679992895
Name:ELBADRI, AHLAM (MD)
Entity Type:Individual
Prefix:
First Name:AHLAM
Middle Name:
Last Name:ELBADRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 S FREMONT AVE STE 2300
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2233
Mailing Address - Country:US
Mailing Address - Phone:417-820-5600
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE STE 2300
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2233
Practice Address - Country:US
Practice Address - Phone:417-820-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2017043198207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program