Provider Demographics
NPI:1780094409
Name:ELGENDY, AHMED
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:
Last Name:ELGENDY
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 1:1055 ROLLINS RD APT 101
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-2511
Mailing Address - Country:US
Mailing Address - Phone:650-669-4559
Mailing Address - Fax:
Practice Address - Street 1:1055 ROLLINS RD APT 101
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-2511
Practice Address - Country:US
Practice Address - Phone:650-669-4559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD2150502172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver