Provider Demographics
NPI:1245488105
Name:BENTAHAR, IMANE TIYAL (MD)
Entity type:Individual
Prefix:
First Name:IMANE
Middle Name:TIYAL
Last Name:BENTAHAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COMPASS WAY
Mailing Address - Street 2:
Mailing Address - City:EAST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02333-1465
Mailing Address - Country:US
Mailing Address - Phone:781-878-1700
Mailing Address - Fax:508-894-0412
Practice Address - Street 1:1 DONALD'S WAY STE 210
Practice Address - Street 2:
Practice Address - City:EAST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02333
Practice Address - Country:US
Practice Address - Phone:508-350-2300
Practice Address - Fax:508-894-0412
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA258525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1245488105Medicaid
IA56568008Medicare PIN