Basic Information
| Provider Information | |||||||||
| NPI: | 1700813607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALI | ||||||||
| FirstName: | IFTIKHAR | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2613 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648042633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176248730 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2613 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648042633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176248730 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 01/23/2019 | ||||||||
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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 | 207R00000X | 2001007751 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100413450B | 05 | KS | MEDICAID | P00187608 | 01 | RR MEDICARE | OTHER | 100413450D | 05 | KS | MEDICAID | P0116491 | 01 | RR MEDICARE | OTHER | 170944 | 01 | ANTHEM | OTHER | 100199760A | 05 | OK | MEDICAID | 205269418 | 05 | MO | MEDICAID |