=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386803559
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WASEEM AHMED MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2008
-----------------------------------------------------
Last Update Date | 07/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3841 BRICKWAY BLVD
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-8226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-569-2300
-----------------------------------------------------
Fax | 707-569-2383
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3841 BRICKWAY BLVD
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-8226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-569-2300
-----------------------------------------------------
Fax | 707-569-2383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | A 117101
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------