Provider Demographics
NPI:1861874646
Name:BAKDALIEH, AHMAD (MD)
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:BAKDALIEH
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 1:7026 OLD KATY RD STE 276
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2187
Mailing Address - Country:US
Mailing Address - Phone:713-358-0562
Mailing Address - Fax:
Practice Address - Street 1:7026 OLD KATY RD STE 276
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2187
Practice Address - Country:US
Practice Address - Phone:713-358-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71222207U00000X, 2085P0229X, 2085R0202X
TXS58352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1861874646Medicaid