Provider Demographics
NPI:1881776821
Name:AHMED, IMTIAZ (MD)
Entity type:Individual
Prefix:
First Name:IMTIAZ
Middle Name:
Last Name:AHMED
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 1:10835 N 25TH AVE
Mailing Address - Street 2:STE 240
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3458
Mailing Address - Country:US
Mailing Address - Phone:602-521-6200
Mailing Address - Fax:623-842-5640
Practice Address - Street 1:2323 W ROSE GARDEN LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-2530
Practice Address - Country:US
Practice Address - Phone:602-521-6200
Practice Address - Fax:623-842-5640
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ355552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ326723Medicaid
AZZ165696Medicare PIN
I45265Medicare UPIN