Provider Demographics
NPI:1306853221
Name:DABABNEH, MALIK (DO)
Entity Type:Individual
Prefix:
First Name:MALIK
Middle Name:
Last Name:DABABNEH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 GREENFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-6004
Mailing Address - Country:US
Mailing Address - Phone:313-945-9000
Mailing Address - Fax:313-945-7500
Practice Address - Street 1:6050 GREENFIELD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-6004
Practice Address - Country:US
Practice Address - Phone:313-945-9000
Practice Address - Fax:313-945-7500
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-087287207Q00000X
MI5101009532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-087287Medicaid
ILK12411Medicare ID - Type Unspecified
IL036-087287Medicaid