Provider Demographics
NPI:1336428523
Name:IMTEYAZ, HEJAB (MD)
Entity Type:Individual
Prefix:DR
First Name:HEJAB
Middle Name:
Last Name:IMTEYAZ
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 1:24430 MILLSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3098
Mailing Address - Country:US
Mailing Address - Phone:703-957-2004
Mailing Address - Fax:
Practice Address - Street 1:24430 MILLSTREAM DR
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105-3098
Practice Address - Country:US
Practice Address - Phone:703-957-2004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD455379208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103044530Medicaid
PA103044530Medicaid