Basic Information
| Provider Information | |||||||||
| NPI: | 1124033808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AL-TARIQ | ||||||||
| FirstName: | QUAZI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 41 DOLSON AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109406489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453442573 | ||||||||
| FaxNumber: | 8453411771 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 DOLSON AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109406489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453442573 | ||||||||
| FaxNumber: | 8453411771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084F0202X | 176250 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0800X | 176250 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 02463472 | 05 | NY | MEDICAID |