Provider Demographics
NPI:1588651897
Name:BOHRA, MUSTAFA SIRAJ (MD)
Entity Type:Individual
Prefix:MR
First Name:MUSTAFA
Middle Name:SIRAJ
Last Name:BOHRA
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 1:6950 CARLYLE CROSSING
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3082
Mailing Address - Country:US
Mailing Address - Phone:248-471-5469
Mailing Address - Fax:248-478-5307
Practice Address - Street 1:15120 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2916
Practice Address - Country:US
Practice Address - Phone:313-582-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067914207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4566492Medicaid
MI743107704OtherTAX IDENTIFICATION
MI743107704OtherTAX IDENTIFICATION
0N83860Medicare PIN