Provider Demographics
NPI:1083866107
Name:HAFZALAH, MINA (MD)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:HAFZALAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 ST. ANTOINE
Mailing Address - Street 2:UHC 5D - MAILBOX 226
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-5629
Practice Address - Fax:313-966-0105
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1172892080P0203X
MI43015025392080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301502539OtherSTATE LICENSE
SD7548OtherSTATE LICENSE
IL036.117289OtherSTATE LICENSE