Provider Demographics
NPI:1831175959
Name:HOOSHMAND, AHMAD M (MD)
Entity type:Individual
Prefix:DR
First Name:AHMAD
Middle Name:M
Last Name:HOOSHMAND
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 1:915 SOUTHWEST BLVD
Mailing Address - Street 2:#E
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5014
Mailing Address - Country:US
Mailing Address - Phone:573-634-4700
Mailing Address - Fax:573-635-4003
Practice Address - Street 1:915 SOUTHWEST BLVD
Practice Address - Street 2:#E
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5014
Practice Address - Country:US
Practice Address - Phone:573-634-4700
Practice Address - Fax:573-635-4003
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1B542084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015436OtherMEDICARE GROUP
MO201565512Medicaid
MO006735436Medicare PIN
A24757Medicare UPIN
MO000015436OtherMEDICARE GROUP