Provider Demographics
NPI:1407892292
Name:IMAM, MOHAMMED N (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:N
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 1:501 SEAVIEW AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3419
Mailing Address - Country:US
Mailing Address - Phone:718-226-6201
Mailing Address - Fax:718-226-1563
Practice Address - Street 1:501 SEAVIEW AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3419
Practice Address - Country:US
Practice Address - Phone:718-226-6201
Practice Address - Fax:718-226-1563
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285039208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64050214Medicaid
KYK056510Medicare PIN
KY64050214Medicaid