Provider Demographics
NPI:1184622342
Name:KEMMOU, AHMED (MD)
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:
Last Name:KEMMOU
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 87
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-6932
Mailing Address - Country:US
Mailing Address - Phone:928-344-5055
Mailing Address - Fax:928-344-5655
Practice Address - Street 1:1841 W 25TH ST STE C
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6920
Practice Address - Country:US
Practice Address - Phone:928-344-5055
Practice Address - Fax:928-344-5655
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36282208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2000258000Medicaid
AZ180902Medicaid
WV2000258000Medicaid
AZ180902Medicaid
AZZ114541Medicare PIN
H43372Medicare UPIN
AZDF8436Medicare PIN
AZP00396559Medicare PIN