Healthcare Provider Details

I. General information

NPI: 1275917361
Provider Name (Legal Business Name): MUSHTAQUE AHMED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER BLVD STE 200
CONROE TX
77304-2821
US

IV. Provider business mailing address

100 E LANCASTER AVE
WYNNEWOOD PA
19096-3450
US

V. Phone/Fax

Practice location:
  • Phone: 936-441-9680
  • Fax:
Mailing address:
  • Phone: 484-476-6421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD476166
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD476166
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberS5539
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: