Provider Demographics
NPI:1316181225
Name:AMIN, AMAR MANOJ
Entity Type:Individual
Prefix:
First Name:AMAR
Middle Name:MANOJ
Last Name:AMIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678132
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8132
Mailing Address - Country:US
Mailing Address - Phone:800-475-3698
Mailing Address - Fax:
Practice Address - Street 1:250 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741
Practice Address - Country:US
Practice Address - Phone:626-963-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1292562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology