=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053818237
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAHMINA AHMAD DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2018
-----------------------------------------------------
Last Update Date | 05/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1684 BUSH LN
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-365-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1684 BUSH LN
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933-3364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-365-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 02006394A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------