Provider Demographics
NPI:1902895949
Name:HORANI, IMAD E (MD)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:E
Last Name:HORANI
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-7875
Mailing Address - Fax:260-373-9705
Practice Address - Street 1:2231 CAREW ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4713
Practice Address - Country:US
Practice Address - Phone:260-266-5230
Practice Address - Fax:260-373-9393
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034917207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000638370OtherANTHEM
INP00785645OtherMEDICARE RR
IN4047092OtherAETNA PROVIDER NUMBER
IN2765686001OtherCIGNA PROVIDER NUMBER
IN0000000084166OtherBCBS PROVIDER NUMBER
IN100006559OtherRAILROAD MEDICARE
IN100331610Medicaid
OH3019003Medicaid
IN0000000084166OtherBCBS PROVIDER NUMBER
IN058020AMedicare ID - Type Unspecified
IN264340AMedicare PIN