Provider Demographics
NPI:1124093414
Name:HUSSAIN, AHMER
Entity type:Individual
Prefix:
First Name:AHMER
Middle Name:
Last Name:HUSSAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N BROADWAY ST
Mailing Address - Street 2:P.O. BOX 787
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2609
Mailing Address - Country:US
Mailing Address - Phone:918-649-0731
Mailing Address - Fax:918-649-3960
Practice Address - Street 1:1001 N BROADWAY ST
Practice Address - Street 2:BOX 787
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2609
Practice Address - Country:US
Practice Address - Phone:918-649-0731
Practice Address - Fax:918-649-3960
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18988207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100108690EMedicaid
OK200038910BMedicaid
OK020654565002OtherBCBS
OK245429303Medicare PIN
OK244502501Medicare PIN
OK$$$$$$$$$-006Medicare PIN
OK020654565002OtherBCBS