Provider Demographics
NPI:1174510275
Name:AHADI, SOUDABEH (MD)
Entity Type:Individual
Prefix:
First Name:SOUDABEH
Middle Name:
Last Name:AHADI
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 1:55 COLE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4103
Mailing Address - Country:US
Mailing Address - Phone:734-242-2022
Mailing Address - Fax:734-242-2251
Practice Address - Street 1:55 COLE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4103
Practice Address - Country:US
Practice Address - Phone:734-242-2022
Practice Address - Fax:734-242-2251
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI036376207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1096347Medicaid
MIA76649Medicare UPIN
MI1096347Medicaid