MEDICARE: DR. IMAM EKO TJAHJA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician	J9393	TX
2	207R00000X	Internal Medicine Physician	J9393	TX
3	207RC0000X	Cardiovascular Disease Physician	J9393	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	629794AS1D	OTHER	TX	MEDICARE ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760472948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IMAM EKO TJAHJA MD

Provider Business Mailing Address
First Line	:	PO BOX 846098
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-6098
Country	:	US
Telephone Number	:	903-606-6400
Fax Number	:	903-606-1522

Provider Business Practice Location Address
First Line	:	12340 BANDERA RD STE 104
Second Line	:
City	:	HELOTES
State	:	TX
Zip	:	78023
Country	:	US
Telephone Number	:	210-920-8000
Fax Number	:	210-920-6000

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	09/09/2025

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Directions to “ DR. IMAM EKO TJAHJA MD” Practice Location

Language	Start Address	Practice Location

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