Provider Demographics
NPI:1689649923
Name:ABDULRAZZAK, MAMDOUH (MD)
Entity Type:Individual
Prefix:MR
First Name:MAMDOUH
Middle Name:
Last Name:ABDULRAZZAK
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 1:4700 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4124
Mailing Address - Country:US
Mailing Address - Phone:313-563-3332
Mailing Address - Fax:
Practice Address - Street 1:4700 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4124
Practice Address - Country:US
Practice Address - Phone:313-945-6100
Practice Address - Fax:313-945-5260
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063026207RS0012X
MIMA01630262084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4272199Medicaid
MI5209224Medicaid
MIMI3231001Medicare PIN
MI4272199Medicaid
MI0N13770016Medicare PIN
MI0P54730Medicare PIN