Provider Demographics
NPI:1114979515
Name:AWADA, MARIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:AWADA
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:PO BOX 44047
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0047
Mailing Address - Country:US
Mailing Address - Phone:248-540-1900
Mailing Address - Fax:248-540-3700
Practice Address - Street 1:30603 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-7729
Practice Address - Country:US
Practice Address - Phone:248-540-1900
Practice Address - Fax:248-540-3700
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082433208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315014950OtherLICENSE
BA8338267OtherDEAE
MI5315014950OtherLICENSE
MIN78910001Medicare PIN