Provider Demographics
NPI:1992774129
Name:AHMAD, BAKHTIAR (MD)
Entity type:Individual
Prefix:
First Name:BAKHTIAR
Middle Name:
Last Name:AHMAD
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 1:264 N HIGHLAND SPRINGS AVE
Mailing Address - Street 2:BLDG 3 SUITE C
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220
Mailing Address - Country:US
Mailing Address - Phone:951-845-4586
Mailing Address - Fax:951-845-6988
Practice Address - Street 1:264 N HIGHLAND SPRINGS AVE
Practice Address - Street 2:BLDG 3 SUITE C
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220
Practice Address - Country:US
Practice Address - Phone:951-845-4586
Practice Address - Fax:951-845-6988
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42585208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A425850Medicaid
CA00A425850Medicaid
CA00A425850Medicare PIN