Basic Information
| Provider Information | |||||||||
| NPI: | 1811931512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALWAN | ||||||||
| FirstName: | IMAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | ONE CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | L9068 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 168137102 | 05 | TX | MEDICAID | 752616977029 | 01 | TX | TRICARE | OTHER | 752616977073 | 01 | TX | TRICARE | OTHER | 8V5490 | 01 | TX | BCBS | OTHER |