Provider Demographics
NPI:1861485831
Name:KADRI, ADEBAMBO MUSTAPHA (MD)
Entity Type:Individual
Prefix:DR
First Name:ADEBAMBO
Middle Name:MUSTAPHA
Last Name:KADRI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MUSTAPHA
Other - Middle Name:ADEBAMBO
Other - Last Name:KADRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0779
Mailing Address - Country:US
Mailing Address - Phone:989-754-3000
Mailing Address - Fax:989-754-3006
Practice Address - Street 1:1015 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601
Practice Address - Country:US
Practice Address - Phone:989-754-3000
Practice Address - Fax:989-754-3006
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105600208G00000X
NY230275-1208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02497661Medicaid
NYG15905Medicare UPIN
NY02497661Medicaid