Healthcare Provider Details

I. General information

NPI: 1467316059
Provider Name (Legal Business Name): MR. ABDUL AKTHAR AHAMATH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 S PROSPECT AVE STE A
TUSTIN CA
92780-1523
US

IV. Provider business mailing address

1513 S HAMPSTEAD ST APT B
ANAHEIM CA
92802-2548
US

V. Phone/Fax

Practice location:
  • Phone: 415-646-6223
  • Fax:
Mailing address:
  • Phone: 657-272-3207
  • Fax: 657-272-3207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberW9193386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: