Provider Demographics
NPI:1215028402
Name:IMAMURA, MICHIAKI (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MICHIAKI
Middle Name:
Last Name:IMAMURA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6621 FANNIN STREET
Mailing Address - Street 2:WT-19345H
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2399
Mailing Address - Country:US
Mailing Address - Phone:832-826-1929
Mailing Address - Fax:832-825-1904
Practice Address - Street 1:6621 FANNIN STREET
Practice Address - Street 2:WT-19345H
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2399
Practice Address - Country:US
Practice Address - Phone:832-826-1929
Practice Address - Fax:832-825-1904
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3474208600000X, 208G00000X
TX45912208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148197001Medicaid
AR02100031400OtherQUALCHOICE
H68691Medicare UPIN
AR5M340Medicare ID - Type Unspecified