Provider Demographics
NPI:1518152347
Name:MAMEDOV, OKTAI (MD)
Entity Type:Individual
Prefix:
First Name:OKTAI
Middle Name:
Last Name:MAMEDOV
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:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-0107
Mailing Address - Country:US
Mailing Address - Phone:443-248-1877
Mailing Address - Fax:888-501-3585
Practice Address - Street 1:3515 COOLIDGE RD
Practice Address - Street 2:UNIT A
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8014
Practice Address - Country:US
Practice Address - Phone:517-755-6888
Practice Address - Fax:888-501-3585
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096000207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518152347OtherBC OF MICHIGAN, ALL PRODUCTS
MI1518152347Medicaid
MI1518152347Medicaid