Provider Demographics
NPI:1427637644
Name:IMAM, ABRAHIM
Entity type:Individual
Prefix:
First Name:ABRAHIM
Middle Name:
Last Name:IMAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-6556
Mailing Address - Country:US
Mailing Address - Phone:662-377-2189
Mailing Address - Fax:662-377-2667
Practice Address - Street 1:1665 S GREEN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6556
Practice Address - Country:US
Practice Address - Phone:662-377-2189
Practice Address - Fax:662-377-2667
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ALDO.3848207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program