Basic Information
| Provider Information | |||||||||
| NPI: | 1366068975 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AHMAD | ||||||||
| FirstName: | MANAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 N COUNTY RD, LEVEL 2 CMO SUITE, INTERNAL MEDICINE RE | ||||||||
| Address2: | MATHER HOSPITAL | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316862517 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75 N COUNTY RD, LEVEL 2 CMO SUITE, INTERNAL MEDICINE RE | ||||||||
| Address2: | MATHER HOSPITAL | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316862517 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2020 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/17/2022 | ||||||||
| NPIReactivationDate: | 02/02/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.