Provider Demographics
NPI:1164837639
Name:FANNY, HABIB M (MD)
Entity Type:Individual
Prefix:DR
First Name:HABIB
Middle Name:M
Last Name:FANNY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHAMED
Other - Middle Name:H
Other - Last Name:FANNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7188
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-0188
Mailing Address - Country:US
Mailing Address - Phone:734-626-4663
Mailing Address - Fax:
Practice Address - Street 1:1255 HILYARD ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3718
Practice Address - Country:US
Practice Address - Phone:541-686-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD197395208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ044997Medicaid