Provider Demographics
NPI:1184677585
Name:BASTAWROS, IMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:IMAN
Middle Name:
Last Name:BASTAWROS
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 1:4441 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2405
Mailing Address - Country:US
Mailing Address - Phone:937-298-7351
Mailing Address - Fax:937-298-9458
Practice Address - Street 1:4441 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2405
Practice Address - Country:US
Practice Address - Phone:937-298-7351
Practice Address - Fax:937-298-9458
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.132323207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000494990OtherANTHEM
KY64128341Medicaid
OH2992141Medicaid
OH2992141Medicaid
KY0398433Medicare PIN
00954027Medicare PIN