Provider Demographics
NPI:1205944097
Name:ALI, ATTIYA
Entity type:Individual
Prefix:
First Name:ATTIYA
Middle Name:
Last Name:ALI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 PALM BAY RD NE STE 3
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2937
Mailing Address - Country:US
Mailing Address - Phone:321-984-8808
Mailing Address - Fax:321-676-7011
Practice Address - Street 1:2105 PALM BAY RD. NE
Practice Address - Street 2:SUITE 3
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2937
Practice Address - Country:US
Practice Address - Phone:321-984-8808
Practice Address - Fax:321-676-7011
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00621082080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL224328OtherAMERIGROUP
FL373757800Medicaid
FL23941OtherBCBS
FL4399726OtherAETNA