Provider Demographics
NPI:1215901848
Name:IMAMI, EMRAN RIAZ (MD)
Entity type:Individual
Prefix:DR
First Name:EMRAN
Middle Name:RIAZ
Last Name:IMAMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33428
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-0428
Mailing Address - Country:US
Mailing Address - Phone:321-733-1901
Mailing Address - Fax:321-733-0211
Practice Address - Street 1:1140 BROADBAND DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2623
Practice Address - Country:US
Practice Address - Phone:321-733-1901
Practice Address - Fax:321-733-0211
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56101208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370625700Medicaid
FL370625700Medicaid
FLK7072Medicare ID - Type Unspecified