Provider Demographics
NPI: | 1669439600 |
---|---|
Name: | HOSSAIN, IMTIAZ (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | IMTIAZ |
Middle Name: | |
Last Name: | HOSSAIN |
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: | 101 CLEARWATER-LARGO RD N #2 |
Mailing Address - Street 2: | |
Mailing Address - City: | LARGO |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33770-2357 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 727-588-0366 |
Mailing Address - Fax: | 727-588-0370 |
Practice Address - Street 1: | 101 CLEARWATER-LARGO RD N #2 |
Practice Address - Street 2: | |
Practice Address - City: | LARGO |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33770-2357 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-588-0366 |
Practice Address - Fax: | 727-588-0370 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-26 |
Last Update Date: | 2012-02-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME70148 | 207LP2900X, 208VP0014X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | E0067Z | Medicare ID - Type Unspecified | |
FL | G61656 | Medicare UPIN |