Provider Demographics
NPI:1609307966
Name:IMANI, GHASEM (MD)
Entity Type:Individual
Prefix:DR
First Name:GHASEM
Middle Name:
Last Name:IMANI
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:MSC 11 6093 1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-6225
Mailing Address - Fax:
Practice Address - Street 1:2400 UNSER BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3392
Practice Address - Country:US
Practice Address - Phone:505-253-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2021-0880208800000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208800000XAllopathic & Osteopathic PhysiciansUrology