Basic Information
| Provider Information | |||||||||
| NPI: | 1821352824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AHMAD | ||||||||
| FirstName: | SUFIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 DREXLER CIR STE 1 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427017843 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 DREXLER CIR STE 1 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427017843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705062730 | ||||||||
| FaxNumber: | 2709000704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2012 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | 48695 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7100250610 | 05 | KY | MEDICAID |