Basic Information
| Provider Information | |||||||||
| NPI: | 1184622342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEMMOU | ||||||||
| FirstName: | AHMED | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87 | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853666932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283445055 | ||||||||
| FaxNumber: | 9283445655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1841 W 25TH ST STE C | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853646920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283445055 | ||||||||
| FaxNumber: | 9283445655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 36282 | AZ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2000258000 | 05 | WV | MEDICAID | 180902 | 05 | AZ | MEDICAID |