Healthcare Provider Details

I. General information

NPI: 1386875011
Provider Name (Legal Business Name): AHMAD FORA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 LILLY RD NE
OLYMPIA WA
98506-5028
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-8880
  • Fax: 360-810-3697
Mailing address:
  • Phone: 239-432-8331
  • Fax: 813-321-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD60628996
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD60628996
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: