Provider Demographics
NPI:1154407310
Name:HAIDER, AHMED GOLAM
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:GOLAM
Last Name:HAIDER
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 1:125 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3448
Mailing Address - Country:US
Mailing Address - Phone:917-634-9445
Mailing Address - Fax:917-634-9444
Practice Address - Street 1:1466 SAINT PETERS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3304
Practice Address - Country:US
Practice Address - Phone:917-634-9445
Practice Address - Fax:971-634-9444
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02215281Medicaid
NY02215281Medicaid
NYH71603Medicare UPIN