Healthcare Provider Details

I. General information

NPI: 1720926744
Provider Name (Legal Business Name): AHMAD ALTAJAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 2ND ST E
BRADENTON FL
34208-1000
US

IV. Provider business mailing address

190 SCOFIELD AVE # 2
BRIDGEPORT CT
06605-2925
US

V. Phone/Fax

Practice location:
  • Phone: 941-746-5111
  • Fax:
Mailing address:
  • Phone: 203-522-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN45699
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: