Provider Demographics
NPI:1780643288
Name:HABRA, GHIYATH K (MD)
Entity Type:Individual
Prefix:
First Name:GHIYATH
Middle Name:K
Last Name:HABRA
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 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010631422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300F362480OtherBCBSM
MICC3460OtherMEDICARE RR GROUP PIN
MI4294051Medicaid
MICA5300OtherMEDICARE RR GROUP PIN
MICC3460OtherMEDICARE RR GROUP PIN
MI0F36248069Medicare PIN
MICA5300OtherMEDICARE RR GROUP PIN
MIP41100010Medicare PIN
MI0P41100Medicare PIN