Provider Demographics
NPI:1790168557
Name:ISLAM, SUMAIYA
Entity Type:Individual
Prefix:
First Name:SUMAIYA
Middle Name:
Last Name:ISLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 W BETHUNE ST
Mailing Address - Street 2:1205
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2600
Mailing Address - Country:US
Mailing Address - Phone:313-335-6195
Mailing Address - Fax:
Practice Address - Street 1:3370 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4236
Practice Address - Country:US
Practice Address - Phone:313-656-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108155207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine