Provider Demographics
NPI:1720439417
Name:AL IKHWAN, MAHDI
Entity Type:Individual
Prefix:
First Name:MAHDI
Middle Name:
Last Name:AL IKHWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 QUEENS BLVD
Mailing Address - Street 2:APT 4X
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1276 FULTON AVE
Practice Address - Street 2:4TH FLOOR FAMILY MEDICINE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3402
Practice Address - Country:US
Practice Address - Phone:718-901-8297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAT-1823194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine