Provider Demographics
NPI:1053382861
Name:AHMADINEJAD, ALI S (MD)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:S
Last Name:AHMADINEJAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ALI
Other - Middle Name:
Other - Last Name:AHMADI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1501 LANSDOWNE AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023-1333
Mailing Address - Country:US
Mailing Address - Phone:610-534-6210
Mailing Address - Fax:610-534-6209
Practice Address - Street 1:1501 LANSDOWNE AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1333
Practice Address - Country:US
Practice Address - Phone:610-534-6210
Practice Address - Fax:610-534-6209
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038453L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB34272Medicare UPIN
PA044074Medicare PIN