Provider Demographics
NPI:1689298945
Name:AL-TABAQCHALI, AHMED MUTHANNA (MD)
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:MUTHANNA
Last Name:AL-TABAQCHALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 E HAMMOND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48302
Mailing Address - Country:US
Mailing Address - Phone:212-423-6271
Mailing Address - Fax:
Practice Address - Street 1:2001 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5148
Practice Address - Country:US
Practice Address - Phone:904-639-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME169270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty