Provider Demographics
NPI:1437362480
Name:SOUTHLAKE NEUROLOGY AND
Entity Type:Organization
Organization Name:SOUTHLAKE NEUROLOGY AND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-421-2905
Mailing Address - Street 1:175 STONEBRIDGE LN STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0307
Mailing Address - Country:US
Mailing Address - Phone:817-421-2905
Mailing Address - Fax:817-431-6459
Practice Address - Street 1:175 STONEBRIDGE LN STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-0307
Practice Address - Country:US
Practice Address - Phone:817-421-2905
Practice Address - Fax:817-431-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10582985OtherCAQH ID
TXK9573OtherTEXAS LICENSE