Provider Demographics
NPI:1720146384
Name:AHMAD, IMTIAZ (MD)
Entity Type:Individual
Prefix:DR
First Name:IMTIAZ
Middle Name:
Last Name:AHMAD
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 1:4567 CROSSROADS PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:201-454-0136
Practice Address - Street 1:308 WILLOW AVE.
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3808
Practice Address - Country:US
Practice Address - Phone:201-418-1420
Practice Address - Fax:201-418-1983
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03908600207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3626202Medicaid
C30309Medicare UPIN
NJ520490Medicare PIN