Basic Information
| Provider Information | |||||||||
| NPI: | 1801829098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMNANI | ||||||||
| FirstName: | IMRAN | ||||||||
| MiddleName: | Q | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12470 TELECOM DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137796303 | ||||||||
| FaxNumber: | 8889771998 | ||||||||
| Practice Location | |||||||||
| Address1: | LAKE CITY VA | ||||||||
| Address2: | 619 S. MARION AVE | ||||||||
| City: | LAKECITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320253202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 12/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME98459 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RI0200X | ME98459 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 208M00000X | ME98459 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | ME98459 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 279501900 | 05 | FL | MEDICAID |