1326474438 NPI number — KHALISA ISRAT JAHAN SYEDA D.O.

Table of content: KHALISA ISRAT JAHAN SYEDA D.O. (NPI 1326474438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326474438 NPI number — KHALISA ISRAT JAHAN SYEDA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SYEDA
Provider First Name:
KHALISA
Provider Middle Name:
ISRAT JAHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326474438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 WESTGATE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36303-3073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-934-3460
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 WESTGATE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-934-3460
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X , with the licence number:  DO.2052 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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