Provider Demographics
NPI:1669744868
Name:MAMSA, KHADIJA AHMAD (MD)
Entity type:Individual
Prefix:
First Name:KHADIJA
Middle Name:AHMAD
Last Name:MAMSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 W PIERCE ST STE 205
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3518
Mailing Address - Country:US
Mailing Address - Phone:575-234-9692
Mailing Address - Fax:
Practice Address - Street 1:2420 W PIERCE ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3543
Practice Address - Country:US
Practice Address - Phone:575-234-9692
Practice Address - Fax:575-887-5237
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0171207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12080845Medicaid
NM12080845Medicaid