Provider Demographics
NPI:1710912464
Name:MOHIUDDIN, IMRAN TAJ (MD)
Entity Type:Individual
Prefix:
First Name:IMRAN
Middle Name:TAJ
Last Name:MOHIUDDIN
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 1:1200 BINZ ST
Mailing Address - Street 2:1180
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-6951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 BINZ ST
Practice Address - Street 2:STE 1180
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-6951
Practice Address - Country:US
Practice Address - Phone:713-520-6790
Practice Address - Fax:713-520-1799
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK86652086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161427305Medicaid
TX8W8513OtherBLUE CROSS BLUE SHIELD
TX8L10073Medicare PIN
TX8W8513OtherBLUE CROSS BLUE SHIELD