Provider Demographics
NPI:1790722718
Name:ALI, TAREQ (MD)
Entity Type:Individual
Prefix:
First Name:TAREQ
Middle Name:
Last Name:ALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W KETTLEMAN LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-9290
Mailing Address - Country:US
Mailing Address - Phone:209-339-3797
Mailing Address - Fax:209-339-3795
Practice Address - Street 1:1520 W KETTLEMAN LN
Practice Address - Street 2:SUITE B
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-9290
Practice Address - Country:US
Practice Address - Phone:209-339-3797
Practice Address - Fax:209-339-3795
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA51048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF49243Medicare UPIN
CA00A510480Medicare ID - Type Unspecified