Provider Demographics
NPI:1265513121
Name:AHMED, SIRAJ K (MD)
Entity type:Individual
Prefix:
First Name:SIRAJ
Middle Name:K
Last Name:AHMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:1112 NORTH MAIN STREET
Mailing Address - Street 2:PMB 311
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-3208
Mailing Address - Country:US
Mailing Address - Phone:209-665-7054
Mailing Address - Fax:209-647-4805
Practice Address - Street 1:520 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4720
Practice Address - Country:US
Practice Address - Phone:209-665-7054
Practice Address - Fax:209-647-4805
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01041335A207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265513121Medicaid
CA238933OtherMEDICARE
IN290009439Medicare PIN
IN100165460Medicaid
IN000000092239OtherANTHEM PROVIDER NUMBER