Provider Demographics
NPI:1598791113
Name:JAWDAT, IMTIHAN M (MD)
Entity Type:Individual
Prefix:MR
First Name:IMTIHAN
Middle Name:M
Last Name:JAWDAT
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 1:2617 C W HOLCOMBE BLVD 322
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1601
Mailing Address - Country:US
Mailing Address - Phone:713-759-9901
Mailing Address - Fax:
Practice Address - Street 1:8901 FM 1960 BYPASS RD W
Practice Address - Street 2:STE. 304
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4018
Practice Address - Country:US
Practice Address - Phone:713-759-9901
Practice Address - Fax:281-501-2927
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9602207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG9602OtherTEXAS STATE LICENSE
TX30068526OtherDPS
TX080242301Medicaid
TX080242301Medicaid
TX080242301Medicaid
TX30068526OtherDPS