Healthcare Provider Details

I. General information

NPI: 1194341321
Provider Name (Legal Business Name): AHMED FAHAD LAZIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5189
US

IV. Provider business mailing address

3401 N BROAD ST
PHILADELPHIA PA
19140-5189
US

V. Phone/Fax

Practice location:
  • Phone: 512-707-2000
  • Fax:
Mailing address:
  • Phone: 215-707-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMT220369
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: