Provider Demographics
NPI:1265513550
Name:IMAM, SHAMIM AKHTAR (MD)
Entity type:Individual
Prefix:
First Name:SHAMIM
Middle Name:AKHTAR
Last Name:IMAM
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 1:504 ELDEN ST # 3
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4741
Mailing Address - Country:US
Mailing Address - Phone:703-471-0800
Mailing Address - Fax:703-471-1332
Practice Address - Street 1:504 ELDEN ST # 3
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4741
Practice Address - Country:US
Practice Address - Phone:703-471-0800
Practice Address - Fax:703-471-1332
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005611377Medicaid
VA005611377Medicaid