Basic Information
| Provider Information | |||||||||
| NPI: | 1952385692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAYYAZ | ||||||||
| FirstName: | IMRAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2107 KLOCKNER RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086903403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095861319 | ||||||||
| FaxNumber: | 6095861468 | ||||||||
| Practice Location | |||||||||
| Address1: | 2107 KLOCKNER RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086903403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095861319 | ||||||||
| FaxNumber: | 6095861468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 0101260631 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 174400000X | 25MA06926000 | NJ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2150009000 | 01 | NJ | AMERIHEALTH HMO | OTHER | 9303718-002 | 01 | NJ | CIGNA | OTHER | 2401109 | 01 | NJ | GHI | OTHER | 2K2723 | 01 | NJ | HEALTHNET | OTHER | 0007528230001 | 01 | NJ | ONE HEALTH PLAN | OTHER | 2959308 | 01 | NJ | AETNA HMO | OTHER | 7204313 | 01 | NJ | AETNA PPO | OTHER | 88151 | 01 | NJ | LOCAL 825 PPO | OTHER | 8856605 | 05 | NJ | MEDICAID | P2646425 | 01 | NJ | OXFORD | OTHER | 1465716 | 01 | NJ | AMERIHEALTH PPO | OTHER | 222233588 | 01 | NJ | HORIZON BC/BS | OTHER | 103482 | 01 | NJ | AMERICAID | OTHER | 2124512 | 01 | NJ | FIRST HEALTH | OTHER | 163917 | 01 | NJ | CHN | OTHER | 222233588 | 01 | NJ | PHCS | OTHER |