Provider Demographics
NPI:1689639353
Name:MOHAMMAD ALI FAISAL, M.D., P.A.
Entity Type:Organization
Organization Name:MOHAMMAD ALI FAISAL, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:FAISAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-758-5985
Mailing Address - Street 1:PO BOX 3009
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-3009
Mailing Address - Country:US
Mailing Address - Phone:386-758-5985
Mailing Address - Fax:386-758-5987
Practice Address - Street 1:1283 SW STATE ROAD 47
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0490
Practice Address - Country:US
Practice Address - Phone:386-758-5985
Practice Address - Fax:386-758-5987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58587174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21142OtherBCBS
FL251378100Medicaid
FL21142Medicare ID - Type Unspecified