Provider Demographics
NPI:1497084842
Name:IMAM, MOHAMED IMAM EL BAHY (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:IMAM EL BAHY
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 1:11307 BRIDGEPORT WAY SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3024
Mailing Address - Country:US
Mailing Address - Phone:253-985-6190
Mailing Address - Fax:253-944-6986
Practice Address - Street 1:11307 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3024
Practice Address - Country:US
Practice Address - Phone:253-985-6190
Practice Address - Fax:253-944-6986
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125052227207R00000X
WAMD60579714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2048593Medicaid