Provider Demographics
NPI:1649215377
Name:KADDOURA, ALI N (MD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:N
Last Name:KADDOURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24825 MICHIGAN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1757
Mailing Address - Country:US
Mailing Address - Phone:313-565-3365
Mailing Address - Fax:313-565-3440
Practice Address - Street 1:24825 MICHIGAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1757
Practice Address - Country:US
Practice Address - Phone:313-565-3365
Practice Address - Fax:313-565-3440
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIAK060472207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3241017Medicaid
G10348Medicare UPIN
0M05210Medicare ID - Type Unspecified