Provider Demographics
NPI:1205071719
Name:RASUL, IMTIAZ (MD)
Entity type:Individual
Prefix:DR
First Name:IMTIAZ
Middle Name:
Last Name:RASUL
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 1:10175 FORTUNE PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6746
Mailing Address - Country:US
Mailing Address - Phone:904-379-8748
Mailing Address - Fax:904-379-8796
Practice Address - Street 1:10175 FORTUNE PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6746
Practice Address - Country:US
Practice Address - Phone:904-379-8748
Practice Address - Fax:904-379-8796
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-1121782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry