Provider Demographics
NPI:1083721161
Name:MASRI CLINIC FOR LASER & COSMETIC
Entity Type:Organization
Organization Name:MASRI CLINIC FOR LASER & COSMETIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-945-9800
Mailing Address - Street 1:13530 MICHIGAN AVENUE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126
Mailing Address - Country:US
Mailing Address - Phone:313-945-9800
Mailing Address - Fax:313-945-9184
Practice Address - Street 1:13530 MICHIGAN AVENUE
Practice Address - Street 2:SUITE 150
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-945-9800
Practice Address - Fax:313-945-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053444208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIFM053444OtherLICENSE
MIFM053444OtherLICENSE
MI0P30670Medicare ID - Type Unspecified