Basic Information
| Provider Information | |||||||||
| NPI: | 1265859755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMANI | ||||||||
| FirstName: | PEACE | ||||||||
| MiddleName: | DOROTHY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1102 BATES AVE STE 245 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328243800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1102 BATES AVE., | ||||||||
| Address2: | BAYLOR COLLEGE OF MEDICINE | ||||||||
| City: | HOUSTON, TX | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328243800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2014 | ||||||||
| LastUpdateDate: | 05/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0210X | 580808 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1265859755 | 05 | TX | MEDICAID |