Provider Demographics
NPI:1710912654
Name:IMAM, TALAT (MD)
Entity Type:Individual
Prefix:MRS
First Name:TALAT
Middle Name:
Last Name:IMAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10058 BAYMEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7177
Mailing Address - Country:US
Mailing Address - Phone:904-636-5400
Mailing Address - Fax:904-928-0654
Practice Address - Street 1:10058 BAYMEADOWS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7177
Practice Address - Country:US
Practice Address - Phone:904-636-5400
Practice Address - Fax:904-928-0654
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018008600Medicaid
FL254712100Medicaid
FL254712100Medicaid
FLM42968ZMedicare PIN
K2754Medicare PIN