Healthcare Provider Details

I. General information

NPI: 1760472948
Provider Name (Legal Business Name): IMAM EKO TJAHJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12340 BANDERA RD STE 104
HELOTES TX
78023
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 210-920-8000
  • Fax: 210-920-6000
Mailing address:
  • Phone: 903-606-6400
  • Fax: 903-606-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberJ9393
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberJ9393
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberJ9393
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: