Provider Demographics
NPI:1336376086
Name:AHMED, ABDUL QUYYUM (MD)
Entity Type:Individual
Prefix:
First Name:ABDUL QUYYUM
Middle Name:
Last Name:AHMED
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 1:2605 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 119
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3568
Mailing Address - Country:US
Mailing Address - Phone:407-878-7990
Mailing Address - Fax:
Practice Address - Street 1:2605 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 119
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3568
Practice Address - Country:US
Practice Address - Phone:407-878-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44333207Q00000X
FLME121657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIM742ZOtherMEDICARE PTAN
KYP400021973Medicare PIN
FLIM742ZOtherMEDICARE PTAN
KYP400021972Medicare PIN
KYP00880435Medicare PIN