Provider Demographics
NPI:1134168388
Name:AHMAD, MUTAHHAR (MD)
Entity type:Individual
Prefix:
First Name:MUTAHHAR
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 1:22972 LAHSER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-4408
Mailing Address - Country:US
Mailing Address - Phone:248-840-7480
Mailing Address - Fax:800-660-6187
Practice Address - Street 1:22972 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-4408
Practice Address - Country:US
Practice Address - Phone:248-840-7480
Practice Address - Fax:800-660-6187
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065663207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4756764Medicaid
G84021Medicare UPIN
MI4756764Medicaid