Provider Demographics
NPI:1013994813
Name:FAZILI, ALI AHMED (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:AHMED
Last Name:FAZILI
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 1:324 E 10TH AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2858
Mailing Address - Country:US
Mailing Address - Phone:801-408-5555
Mailing Address - Fax:801-408-5556
Practice Address - Street 1:324 E 10TH AVE STE 170
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103
Practice Address - Country:US
Practice Address - Phone:801-408-5555
Practice Address - Fax:801-408-5556
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5114957-1205207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H46708Medicare UPIN
H46708Medicare UPIN
004622026Medicare PIN
UTH46708Medicare UPIN