Basic Information
| Provider Information | |||||||||
| NPI: | 1437103629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTAFULLAH | ||||||||
| FirstName: | IRFAN | ||||||||
| MiddleName: | MOHAMMAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.B., B.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880661 | ||||||||
| FaxNumber: | 7632872310 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880661 | ||||||||
| FaxNumber: | 7632872310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 31625 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1437103629 | 05 | MN | MEDICAID | 100277C029 | 01 | MN | UCARE | OTHER | 0265046 | 01 | MN | PREFERRED ONE | OTHER | 0522654 | 01 | MN | MEDICA | OTHER | 1D717AL | 01 | MN | BCBS OF MN | OTHER | 31739300 | 05 | WI | MEDICAID | 130006223 | 01 | MN | RAILROAD MEDICARE | OTHER | HP12787 | 01 | MN | HEALTHPARTNERS | OTHER | 22781 | 01 | MN | AMERICA'S PPO | OTHER |