Healthcare Provider Details

I. General information

NPI: 1710349543
Provider Name (Legal Business Name): AHMAD MOHAMMADIEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 W MARKET ST
LIMA OH
45801-4602
US

IV. Provider business mailing address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-3361
  • Fax:
Mailing address:
  • Phone: 904-639-2000
  • Fax: 904-639-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301509387
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME134693
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.143562
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier107668300
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: