Provider Demographics
NPI:1497052658
Name:IMANI, IBN A (DPM)
Entity Type:Individual
Prefix:DR
First Name:IBN
Middle Name:A
Last Name:IMANI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:IBN
Other - Middle Name:
Other - Last Name:IMANI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:216 W COLLEGE AVE
Mailing Address - Street 2:#871
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-7737
Mailing Address - Country:US
Mailing Address - Phone:850-402-9042
Mailing Address - Fax:
Practice Address - Street 1:1628 N PLAZA DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-2300
Practice Address - Country:US
Practice Address - Phone:850-402-9042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2415213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6714960001Medicare NSC