Healthcare Provider Details

I. General information

NPI: 1013495431
Provider Name (Legal Business Name): KAMRAN HUSSAIN IMAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 LIME ST STE 516
RIVERSIDE CA
92501-0944
US

IV. Provider business mailing address

18111 BROOKHURST ST # 6700
FOUNTAIN VALLEY CA
92708-6728
US

V. Phone/Fax

Practice location:
  • Phone: 951-367-1060
  • Fax:
Mailing address:
  • Phone: 714-688-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberA173489
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA173489
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA173489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: