Provider Demographics
NPI:1720577919
Name:IKHWAN, IMAD
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:
Last Name:IKHWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E PINE ST APT 1512
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-6626
Mailing Address - Country:US
Mailing Address - Phone:562-253-9238
Mailing Address - Fax:
Practice Address - Street 1:52 W UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:321-841-8727
Practice Address - Fax:321-841-4085
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME148029207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine