Provider Demographics
NPI:1376614487
Name:IMAM, HASSAN (MD)
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:
Last Name:IMAM
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 1:1400 WALLACE BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-354-5585
Mailing Address - Fax:806-356-4673
Practice Address - Street 1:3535 TRIPP AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79121-1636
Practice Address - Country:US
Practice Address - Phone:806-212-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240742207Q00000X
TXN0119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine