Healthcare Provider Details

I. General information

NPI: 1255688271
Provider Name (Legal Business Name): AHMAD H OTHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FAIRWAY TER N STE B
CLOVIS NM
88101-3060
US

IV. Provider business mailing address

2508 FAIRWAY TER
CLOVIS NM
88101-2734
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-7779
  • Fax: 575-762-3526
Mailing address:
  • Phone: 312-813-6958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2018-0173
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: