Healthcare Provider Details

I. General information

NPI: 1134183643
Provider Name (Legal Business Name): MOHAMMAD IMANI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4813 MACCORKLE AVE SE
CHARLESTON WV
25304-1948
US

IV. Provider business mailing address

4813 MACCORKLE AVE SE
CHARLESTON WV
25304-1948
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-3338
  • Fax: 304-925-3365
Mailing address:
  • Phone: 304-925-3338
  • Fax: 304-925-3365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number249
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: