Basic Information
| Provider Information | |||||||||
| NPI: | 1942460134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIWANI | ||||||||
| FirstName: | NOOR ALI | ||||||||
| MiddleName: | WALLIMOHAMMED | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JIWANI | ||||||||
| OtherFirstName: | NOORALI | ||||||||
| OtherMiddleName: | W | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2000 OPELOUSAS STREET | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374399983 | ||||||||
| FaxNumber: | 3374393224 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 OPELOUSAS STREET | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374399983 | ||||||||
| FaxNumber: | 3374393224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2008 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD204690 | LA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME107815 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | MD.202288 | LA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1082066 | 05 | LA | MEDICAID |