Healthcare Provider Details

I. General information

NPI: 1598076705
Provider Name (Legal Business Name): ALI A FAROOQUI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8003 LYNDON CENTRE WAY STE 202
LOUISVILLE KY
40222-3604
US

IV. Provider business mailing address

8003 LYNDON CENTRE WAY STE 202
LOUISVILLE KY
40222-3604
US

V. Phone/Fax

Practice location:
  • Phone: 502-327-7701
  • Fax: 502-327-7705
Mailing address:
  • Phone: 502-327-7701
  • Fax: 502-327-7705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2010020458
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number51657
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number51657
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: