Basic Information
| Provider Information | |||||||||
| NPI: | 1124212758 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMTIAZ | ||||||||
| FirstName: | AIZED | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WATER ST | ||||||||
| Address2: | FL 12 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100410004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602583480 | ||||||||
| FaxNumber: | 8605716800 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 SEYMOUR ST | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602440148 | ||||||||
| FaxNumber: | 8604931852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 050464 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 278990 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 050464 | 01 | CT | LICENSE | OTHER |