Basic Information
| Provider Information | |||||||||
| NPI: | 1376597815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAFRI | ||||||||
| FirstName: | AHMED | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1438 S GRAND BLVD | ||||||||
| Address2: | MONTELEONE HALL | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149774883 | ||||||||
| FaxNumber: | 3149774876 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 W JACKSON ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183514972 | ||||||||
| FaxNumber: | 6183516522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | R1P30 | MO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | R1P30 | MO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084V0102X | R1P30 | MO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084N0400X | 036.078345 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 203014618 | 05 | MO | MEDICAID |