Provider Demographics
NPI:1255313979
Name:MOIIN, ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:MOIIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 W BIG BEAVER RD
Mailing Address - Street 2:SUITE C12
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3525
Mailing Address - Country:US
Mailing Address - Phone:248-643-7677
Mailing Address - Fax:248-643-7679
Practice Address - Street 1:1575 W BIG BEAVER RD
Practice Address - Street 2:SUITE C12
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3525
Practice Address - Country:US
Practice Address - Phone:248-643-7677
Practice Address - Fax:248-643-7679
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301059655207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4251045 10Medicaid
MI0M59970Medicare PIN
MI4251045 10Medicaid