Provider Demographics
NPI:1922455146
Name:KIMYAGHALAM, ALI (MD)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:KIMYAGHALAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-637-1600
Mailing Address - Fax:307-637-1699
Practice Address - Street 1:2301 HOUSE AVE STE 301
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3178
Practice Address - Country:US
Practice Address - Phone:307-637-1600
Practice Address - Fax:307-637-1699
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1423902086S0129X
NY311290208600000X
WY18666A2086S0129X
PAMD4809772086S0129X
ID70613772086S0129X
VA01012857952086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty