Provider Demographics
NPI:1093704801
Name:ABDEL-LATIEF, AHMED A (MD)
Entity type:Individual
Prefix:DR
First Name:AHMED
Middle Name:A
Last Name:ABDEL-LATIEF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-239-1433
Mailing Address - Fax:574-239-1438
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-239-1433
Practice Address - Fax:574-239-1438
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052385A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200266710Medicaid
IN200266710Medicaid
IN146470PPPMedicare ID - Type Unspecified