Provider Demographics
NPI:1770875080
Name:AMANI, AHMAD MUSTAFA (MD)
Entity type:Individual
Prefix:DR
First Name:AHMAD
Middle Name:MUSTAFA
Last Name:AMANI
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9235
Mailing Address - Fax:
Practice Address - Street 1:8725 N WICKHAM RD STE 203
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2240
Practice Address - Country:US
Practice Address - Phone:321-434-9535
Practice Address - Fax:321-434-9538
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME150014208600000X
MI4301104514208600000X
TXBP10057814208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN5720OtherHFMG MA
FL111326800Medicaid