Provider Demographics
NPI:1265859755
Name:IMANI, PEACE DOROTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:PEACE
Middle Name:DOROTHY
Last Name:IMANI
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 1:1102 BATES AVE STE 245
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2619
Mailing Address - Country:US
Mailing Address - Phone:832-824-3800
Mailing Address - Fax:
Practice Address - Street 1:1102 BATES AVE.,
Practice Address - Street 2:BAYLOR COLLEGE OF MEDICINE
Practice Address - City:HOUSTON, TX
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:832-824-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5808082080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1265859755Medicaid