=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770376485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AHMED AL-FARTOSI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2025
-----------------------------------------------------
Last Update Date | 05/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 E FLETCHER AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33613-4613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-971-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3811 SHADOW KNOLL CT
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77082-5623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-719-3471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | TRN42538
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------