Provider Demographics
NPI:1093995821
Name:IMAD AL-NAKSHABENDI M D P A
Entity Type:Organization
Organization Name:IMAD AL-NAKSHABENDI M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-NAKSHABENDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-972-3750
Mailing Address - Street 1:5041 WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1376
Mailing Address - Country:US
Mailing Address - Phone:813-972-3750
Mailing Address - Fax:813-972-3749
Practice Address - Street 1:671 S KINGS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6048
Practice Address - Country:US
Practice Address - Phone:813-972-3750
Practice Address - Fax:813-972-3749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79277207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261817600Medicaid
FL51262Medicare PIN
FL261817600Medicaid