Healthcare Provider Details

I. General information

NPI: 1306842869
Provider Name (Legal Business Name): SYED WASIM ALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 SOUTHPARK CIRCLE EAST
ST AUGUSTINE FL
32086
US

IV. Provider business mailing address

P O BOX 1960 US HIGHWAY 1 SOUTH STE 20
ST AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-5386
  • Fax: 904-824-5387
Mailing address:
  • Phone: 904-824-5386
  • Fax: 904-824-5387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME0068402
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: