Provider Demographics
NPI:1134359599
Name:ABOSSALLUE, IMAD (MD)
Entity type:Individual
Prefix:
First Name:IMAD
Middle Name:
Last Name:ABOSSALLUE
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 1:5605 GLENRIDGE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1301
Mailing Address - Country:US
Mailing Address - Phone:404-252-4709
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-6323
Practice Address - Fax:404-303-3747
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121864207R00000X, 207U00000X
MO2009010810207R00000X
MI4301102046207RG0300X
GA88214207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine