Provider Demographics
NPI:1255914842
Name:ALI, AHMED T
Entity type:Individual
Prefix:MR
First Name:AHMED
Middle Name:T
Last Name:ALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 N 31ST AVE STE C264
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-9630
Mailing Address - Country:US
Mailing Address - Phone:205-207-7777
Mailing Address - Fax:
Practice Address - Street 1:10000 N 31ST AVE STE C264
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-9630
Practice Address - Country:US
Practice Address - Phone:205-207-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ548479Medicaid