Provider Demographics
NPI:1336318591
Name:RAZA, IMRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:IMRAN
Middle Name:
Last Name:RAZA
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 1:3320 RINCONADA BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7198
Mailing Address - Country:US
Mailing Address - Phone:575-532-1111
Mailing Address - Fax:575-532-1122
Practice Address - Street 1:3320 RINCONADA BLVD
Practice Address - Street 2:STE 2
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7198
Practice Address - Country:US
Practice Address - Phone:575-532-1111
Practice Address - Fax:575-532-1122
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2010-0103207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42488371Medicaid