Provider Demographics
NPI:1932321361
Name:IMTIAZ, AMENA M (MD)
Entity Type:Individual
Prefix:DR
First Name:AMENA
Middle Name:M
Last Name:IMTIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMENA
Other - Middle Name:M
Other - Last Name:HASAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3495 PIEDMONT ROAD, NE NINE PIEDMONT CENTER
Mailing Address - Street 2:THE SOUTHEAST PERMANENTE MEDICAL GROUP, INC.
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1736
Mailing Address - Country:US
Mailing Address - Phone:205-587-9269
Mailing Address - Fax:
Practice Address - Street 1:20 GLENLAKE PARKWAY
Practice Address - Street 2:KAISER PERMANENTE GLENLAKE MEDICAL CENTER
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:205-934-5038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0648322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology