Basic Information
| Provider Information | |||||||||
| NPI: | 1376776153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AL-MUFTI | ||||||||
| FirstName: | FAWAZ | ||||||||
| MiddleName: | AHMED SAMI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 710 W 168TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123057236 | ||||||||
| FaxNumber: | 2123052792 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 WOODS RD # A | ||||||||
| Address2: | |||||||||
| City: | VALHALLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105951530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144937000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2009 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 270440 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208D00000X | 241152 | MA | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 03782198 | 05 | NY | MEDICAID | 270440 | 01 | NY | NYS LICENSE | OTHER | A400191607 | 01 | NY | MEDICARE | OTHER |