Provider Demographics
NPI:1639482391
Name:TAHBUB, IMAD (MD)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:
Last Name:TAHBUB
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 1:5900 LAKE ELLENOR DR STE 700
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4643
Mailing Address - Country:US
Mailing Address - Phone:407-352-2542
Mailing Address - Fax:407-352-2547
Practice Address - Street 1:5900 LAKE ELLENOR DR STE 700
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4643
Practice Address - Country:US
Practice Address - Phone:407-352-2542
Practice Address - Fax:407-352-2547
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115836208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14R7COtherBCBS
FL009088400Medicaid