Basic Information
Provider Information | |||||||||
NPI: | 1720069214 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AFROOKTEH | ||||||||
FirstName: | ALI | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 W 9TH ST | ||||||||
Address2: |   | ||||||||
City: | FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 217014541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016628119 | ||||||||
FaxNumber: | 3016960985 | ||||||||
Practice Location | |||||||||
Address1: | 300 W 9TH ST | ||||||||
Address2: |   | ||||||||
City: | FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 217014541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016628119 | ||||||||
FaxNumber: | 3016960985 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2005 | ||||||||
LastUpdateDate: | 05/12/2008 | ||||||||
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 | 174400000X | D00355183 | MD | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 110047912 | 01 | MD | MEDICARE RAILROAD | OTHER | 172006924 | 01 | MD | MEDICAID NPI | OTHER | 477571600 | 05 | MD |   | MEDICAID |