Provider Demographics
NPI:1003159104
Name:IMAM, MOHAMMED WASEEM (DO)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:WASEEM
Last Name:IMAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 N COLLINS ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76005-4553
Mailing Address - Country:US
Mailing Address - Phone:817-678-5575
Mailing Address - Fax:
Practice Address - Street 1:4120 N COLLINS ST STE 100
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76005-4553
Practice Address - Country:US
Practice Address - Phone:817-678-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR5274207K00000X
MI5101020271207R00000X
FLOS 13971207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1003159104OtherCOMMERCIAL INSURANCE