Provider Demographics
NPI:1952582157
Name:MEMON, IMRAN ADAM (MD)
Entity Type:Individual
Prefix:DR
First Name:IMRAN
Middle Name:ADAM
Last Name:MEMON
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 1:1000 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3029
Mailing Address - Country:US
Mailing Address - Phone:817-877-5858
Mailing Address - Fax:817-335-4418
Practice Address - Street 1:1001 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2228
Practice Address - Country:US
Practice Address - Phone:817-877-5858
Practice Address - Fax:817-335-4418
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1199207R00000X, 2080P0210X, 207RN0300X, 207RN0300X
MI4301079766207RN0300X, 208000000X, 2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN0195877OtherDPS
TX321658201Medicaid
TXP1199OtherTEXAS LICENSE
MO2007004327OtherMISSOURI LICENSE NUMBER
MO2007004327OtherMISSOURI LICENSE NUMBER
TXFM3786211OtherDEA
TX321658201Medicaid