Provider Demographics
NPI:1467988956
Name:SUFYAN, MAMOON
Entity Type:Individual
Prefix:MR
First Name:MAMOON
Middle Name:
Last Name:SUFYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7911 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1177
Mailing Address - Country:US
Mailing Address - Phone:313-409-0808
Mailing Address - Fax:
Practice Address - Street 1:7911 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1177
Practice Address - Country:US
Practice Address - Phone:313-409-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5803000121343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)