Healthcare Provider Details

I. General information

NPI: 1750133880
Provider Name (Legal Business Name): ALI HAIDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 12TH ST STE C
MODESTO CA
95354-0834
US

IV. Provider business mailing address

1130 12TH ST STE C
MODESTO CA
95354-0834
US

V. Phone/Fax

Practice location:
  • Phone: 209-312-2655
  • Fax:
Mailing address:
  • Phone: 209-312-2655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: