Basic Information
| Provider Information | |||||||||
| NPI: | 1043591514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALI | ||||||||
| FirstName: | OSAMA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 701 W PLYMOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | DELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327203236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3869433160 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W PLYMOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | DELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327203236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3869433160 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2011 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D81150 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME145034 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 108073300 | 05 | MD | MEDICAID |