Provider Demographics
NPI:1891722385
Name:IMAM, HUSSAIN S (MD)
Entity Type:Individual
Prefix:MR
First Name:HUSSAIN
Middle Name:S
Last Name:IMAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
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:2006-06-28
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81517207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018008600Medicaid
FL020027900Medicaid
FL58755ZMedicare PIN
FL273849000Medicaid
FLF91102Medicare UPIN