Healthcare Provider Details

I. General information

NPI: 1881776821
Provider Name (Legal Business Name): IMTIAZ AHMED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 W ROSE GARDEN LN
PHOENIX AZ
85027-2530
US

IV. Provider business mailing address

10835 N 25TH AVE STE 240
PHOENIX AZ
85029-3458
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-6200
  • Fax: 623-842-5640
Mailing address:
  • Phone: 602-521-6200
  • Fax: 623-842-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35555
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: