Provider Demographics
NPI:1801829098
Name:SAMNANI, IMRAN Q (MD)
Entity Type:Individual
Prefix:MR
First Name:IMRAN
Middle Name:Q
Last Name:SAMNANI
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 1:12470 TELECOM DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0904
Mailing Address - Country:US
Mailing Address - Phone:813-779-6303
Mailing Address - Fax:888-977-1998
Practice Address - Street 1:LAKE CITY VA
Practice Address - Street 2:619 S. MARION AVE
Practice Address - City:LAKECITY
Practice Address - State:FL
Practice Address - Zip Code:32025-3202
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98459207P00000X, 207RI0200X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279501900Medicaid
FLAG120ZMedicare PIN
AG120WMedicare PIN