Healthcare Provider Details

I. General information

NPI: 1437610664
Provider Name (Legal Business Name): AHMED ELMASHAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10080 SW INNOVATION WAY
PORT ST LUCIE FL
34987-2127
US

IV. Provider business mailing address

10080 SW INNOVATION WAY
PORT SAINT LUCIE FL
34987-2127
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-5945
  • Fax:
Mailing address:
  • Phone: 772-332-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number179916
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number328779
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number328779
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number179916
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number179916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: