Healthcare Provider Details

I. General information

NPI: 1932270832
Provider Name (Legal Business Name): ANIS A. AHMADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 SOUTHPARK CIR E
SAINT AUGUSTINE FL
32086-5135
US

IV. Provider business mailing address

216 SOUTHPARK CIR E
SAINT AUGUSTINE FL
32086-5135
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-6108
  • Fax: 904-823-9613
Mailing address:
  • Phone: 904-824-6108
  • Fax: 904-823-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME102708
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME102708
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: