Provider Demographics
NPI:1164466272
Name:ALI, IMAN H (MD)
Entity Type:Individual
Prefix:
First Name:IMAN
Middle Name:H
Last Name:ALI
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 1:2036 BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5709
Mailing Address - Country:US
Mailing Address - Phone:817-685-8018
Mailing Address - Fax:817-685-9484
Practice Address - Street 1:2036 BEDFORD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5709
Practice Address - Country:US
Practice Address - Phone:817-685-8018
Practice Address - Fax:817-685-9484
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9974174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0303661-01Medicaid
TXK 9974OtherLICENSE #
TXBA4145214OtherDEA LICENCE
TXK 9974OtherLICENSE #