Provider Demographics
NPI:1861929580
Name:IMRAN, ALI (MD)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:IMRAN
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 1:1130 W GROVE AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4942
Mailing Address - Country:US
Mailing Address - Phone:480-306-5000
Mailing Address - Fax:480-452-0300
Practice Address - Street 1:1130 W GROVE AVE STE 115
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4942
Practice Address - Country:US
Practice Address - Phone:480-306-5000
Practice Address - Fax:480-452-0300
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ61661208M00000X, 207R00000X
390200000X
WI72994-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100100534Medicaid