Provider Demographics
NPI:1245636042
Name:DR EJAZ AHMED MD PA
Entity type:Organization
Organization Name:DR EJAZ AHMED MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EJAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-235-8731
Mailing Address - Street 1:3848 CALLIOPE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6025
Mailing Address - Country:US
Mailing Address - Phone:386-235-8731
Mailing Address - Fax:386-269-9555
Practice Address - Street 1:405 NORTH CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2730
Practice Address - Country:US
Practice Address - Phone:386-235-8731
Practice Address - Fax:386-269-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty