Healthcare Provider Details

I. General information

NPI: 1013265677
Provider Name (Legal Business Name): SYED MUHAMMAD ALI IMRAN BUKHARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 OVERTON RIDGE BLVD
FORT WORTH TX
76132-3614
US

IV. Provider business mailing address

3341 REGENT BLVD STE 130
IRVING TX
75063-3132
US

V. Phone/Fax

Practice location:
  • Phone: 817-361-1991
  • Fax:
Mailing address:
  • Phone: 903-331-0506
  • Fax: 903-331-0462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.125986
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA149584
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR4372
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: