Provider Demographics
NPI:1760472948
Name:TJAHJA, IMAM EKO (MD)
Entity Type:Individual
Prefix:DR
First Name:IMAM
Middle Name:EKO
Last Name:TJAHJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-606-6400
Mailing Address - Fax:903-606-1522
Practice Address - Street 1:12340 BANDERA RD STE 104
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023
Practice Address - Country:US
Practice Address - Phone:210-920-8000
Practice Address - Fax:210-920-6000
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9393207RI0011X, 207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104420801Medicaid
TX629794AS1DOtherMEDICARE ID
TX104420801Medicaid