Provider Demographics
NPI:1578516597
Name:IMAM, AZHAR (MD)
Entity Type:Individual
Prefix:
First Name:AZHAR
Middle Name:
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 1:56 FRANKLIN ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1221
Mailing Address - Country:US
Mailing Address - Phone:203-709-8873
Mailing Address - Fax:203-709-8689
Practice Address - Street 1:100 JEFFERSON SQUARE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1253
Practice Address - Country:US
Practice Address - Phone:203-709-6200
Practice Address - Fax:203-709-3335
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0428142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001428144Medicaid
CT260004364Medicare ID - Type Unspecified
CTI26004Medicare UPIN