Basic Information
| Provider Information | |||||||||
| NPI: | 1821539271 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AHMED | ||||||||
| FirstName: | IMAN | ||||||||
| MiddleName: | MOHAMOUD | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5055 E BROADWAY BLVD STE A100 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857113629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203821085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7395 E TANQUE VERDE RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857153475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205472311 | ||||||||
| FaxNumber: | 5205472320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2017 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 61323 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 079902 | 05 | AZ | MEDICAID |