Provider Demographics
NPI:1235149899
Name:SOOFI, MOHAMED AMJAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:AMJAD
Last Name:SOOFI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2252 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4254
Mailing Address - Country:US
Mailing Address - Phone:734-241-2726
Mailing Address - Fax:734-241-2744
Practice Address - Street 1:2252 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4254
Practice Address - Country:US
Practice Address - Phone:734-241-2726
Practice Address - Fax:734-241-2744
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMS049788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI14196BOtherHAP
MI3940001003OtherCIGNA
MI0105801292OtherBLUE CROSS BLUE SHIELD
MI4036635OtherAETNA
MI4075860Medicaid
MIOM58900Medicare ID - Type UnspecifiedMEDICARE
MI4075860Medicaid