Basic Information
Provider Information | |||||||||
NPI: | 1205832151 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAVID | ||||||||
FirstName: | AHMAD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AHMAD | ||||||||
OtherFirstName: | JAVID | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 85 SOUTH WEST STREET | ||||||||
Address2: |   | ||||||||
City: | HOMER | ||||||||
State: | NY | ||||||||
PostalCode: | 13077 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077533797 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 24 GROTON AVE | ||||||||
Address2: |   | ||||||||
City: | CORTLAND | ||||||||
State: | NY | ||||||||
PostalCode: | 130452014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077533774 | ||||||||
FaxNumber: | 6077533947 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2005 | ||||||||
LastUpdateDate: | 12/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5166489 | NY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 01669089 | 05 | NY |   | MEDICAID |