Provider Demographics
NPI:1063414969
Name:IMANI, JAHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JAHAN
Middle Name:
Last Name:IMANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9519
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84409-0519
Mailing Address - Country:US
Mailing Address - Phone:801-475-0399
Mailing Address - Fax:801-475-7322
Practice Address - Street 1:5315 ADAMS AVE PKWY
Practice Address - Street 2:STE A
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-4766
Practice Address - Country:US
Practice Address - Phone:801-475-0399
Practice Address - Fax:801-475-7322
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT260615207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT91749924027Medicaid
UT91749924027Medicaid
UT005766001Medicare PIN