Provider Demographics
NPI:1700813607
Name:ALI, IFTIKHAR (MD)
Entity Type:Individual
Prefix:
First Name:IFTIKHAR
Middle Name:
Last Name:ALI
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 1:2705 S RANGE LINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3283
Mailing Address - Country:US
Mailing Address - Phone:417-553-4252
Mailing Address - Fax:
Practice Address - Street 1:2705 S RANGE LINE RD STE A
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3283
Practice Address - Country:US
Practice Address - Phone:417-553-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001007751207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205269418Medicaid
P0116491OtherRR MEDICARE
OK100199760AMedicaid
170944OtherANTHEM
KS100413450BMedicaid
KS100413450DMedicaid
P00187608OtherRR MEDICARE
OK100199760AMedicaid
MO205269418Medicaid
P0116491OtherRR MEDICARE