Provider Demographics
NPI:1396282406
Name:SIRAJ K AHMED MD INC
Entity type:Organization
Organization Name:SIRAJ K AHMED MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-956-9166
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:209-239-9594
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC138466207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265513121Medicaid