=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952582157
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IMRAN ADAM MEMON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2007
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 PENNSYLVANIA AVE
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-2228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-877-5858
-----------------------------------------------------
Fax | 817-335-4418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 W CANNON ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-877-5858
-----------------------------------------------------
Fax | 817-335-4418
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | P1199
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 4301079766
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301079766
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2080P0210X
-----------------------------------------------------
Taxonomy Name | Pediatric Nephrology Physician
-----------------------------------------------------
License Number | 4301079766
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | P1199
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2080P0210X
-----------------------------------------------------
Taxonomy Name | Pediatric Nephrology Physician
-----------------------------------------------------
License Number | P1199
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------