Provider Demographics
NPI:1366560484
Name:JAHAN IMANI MD PC
Entity type:Organization
Organization Name:JAHAN IMANI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IMANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-475-7707
Mailing Address - Street 1:P.O. BOX 9519
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84409
Mailing Address - Country:US
Mailing Address - Phone:801-475-7707
Mailing Address - Fax:801-475-7322
Practice Address - Street 1:5315 ADAMS AVE PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-4766
Practice Address - Country:US
Practice Address - Phone:801-475-5950
Practice Address - Fax:801-475-7322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57891911205174400000X
UT58040891205174400000X
UT51777271205174400000X
UT2606151205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057660OtherGOUP MEDICARE NUMBER
UT3010760Medicaid