Provider Demographics
NPI:1558989491
Name:IMAM, NUVAIR ALI (MD)
Entity Type:Individual
Prefix:
First Name:NUVAIR
Middle Name:ALI
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 1:110 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5674
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:508-894-0412
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5674
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-894-0412
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1013057207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine