Provider Demographics
NPI:1134489651
Name:IMAM, TANBEENA (MD)
Entity Type:Individual
Prefix:
First Name:TANBEENA
Middle Name:
Last Name:IMAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST STE M-351
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5358
Mailing Address - Country:US
Mailing Address - Phone:269-341-7784
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-351
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5358
Practice Address - Country:US
Practice Address - Phone:269-341-7784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301116025208000000X, 2080P0206X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program