Provider Demographics
NPI:1871115709
Name:AL-WAISI, AHMED
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:
Last Name:AL-WAISI
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 1:999 SAN BERNARDINO RD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4920
Mailing Address - Country:US
Mailing Address - Phone:909-985-2811
Mailing Address - Fax:
Practice Address - Street 1:999 SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4920
Practice Address - Country:US
Practice Address - Phone:909-985-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA183713207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program