Basic Information
| Provider Information | |||||||||
| NPI: | 1497084842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMAM | ||||||||
| FirstName: | MOHAMED | ||||||||
| MiddleName: | IMAM EL BAHY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539856190 | ||||||||
| FaxNumber: | 2539446986 | ||||||||
| Practice Location | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539856190 | ||||||||
| FaxNumber: | 2539446986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2009 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125052227 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD60579714 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2048593 | 05 | WA | MEDICAID |