Healthcare Provider Details

I. General information

NPI: 1962719187
Provider Name (Legal Business Name): DR SYED W. ALI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 OSCEOLA ELEMENTARY RD STE A
ST AUGUSTINE FL
32084-5942
US

IV. Provider business mailing address

2465 US HIGHWAY 1 S STE NO19
ST AUGUSTINE FL
32086-6076
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7476
  • Fax: 904-824-7078
Mailing address:
  • Phone: 904-824-7476
  • Fax: 904-824-7078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SYED WASIM ALI
Title or Position: PRESIDENT
Credential: MD
Phone: 904-824-5386