Provider Demographics
NPI:1235163767
Name:IMANI, MANOUCHEHR M (MD)
Entity Type:Individual
Prefix:
First Name:MANOUCHEHR
Middle Name:M
Last Name:IMANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 N SAN ANTONIO AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784
Mailing Address - Country:US
Mailing Address - Phone:951-248-9113
Mailing Address - Fax:951-248-9115
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-5701
Practice Address - Fax:951-486-5705
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A548921Medicaid
CA01/14/1936OtherDOB
CA00A548920Medicare ID - Type UnspecifiedMEDICARE
CA00A548921Medicaid