Healthcare Provider Details

I. General information

NPI: 1679767925
Provider Name (Legal Business Name): ALI ABDUL WAHID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 WARD AVE BLDG A
PATTERSON CA
95363-8529
US

IV. Provider business mailing address

1108 WARD AVE BLDG A STE 1
PATTERSON CA
95363
US

V. Phone/Fax

Practice location:
  • Phone: 209-892-9100
  • Fax:
Mailing address:
  • Phone: 209-892-1300
  • Fax: 209-780-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD432706
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2007034473
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA106703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: