Provider Demographics
NPI:1184604696
Name:FATHALA, AHMED (MD)
Entity type:Individual
Prefix:DR
First Name:AHMED
Middle Name:
Last Name:FATHALA
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 1:2745 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-7201
Mailing Address - Country:US
Mailing Address - Phone:563-242-3208
Mailing Address - Fax:563-242-4051
Practice Address - Street 1:2745 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-7201
Practice Address - Country:US
Practice Address - Phone:563-242-3208
Practice Address - Fax:563-242-4051
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0448019Medicaid
IA0448019Medicaid
IAI14217Medicare ID - Type Unspecified