Provider Demographics
NPI:1881045847
Name:EZWAWI, SOUMAYA (MD)
Entity Type:Individual
Prefix:
First Name:SOUMAYA
Middle Name:
Last Name:EZWAWI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 SCIO VILLAGE CT UNIT 173
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9146
Mailing Address - Country:US
Mailing Address - Phone:734-486-2884
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-1328
Practice Address - Fax:517-205-1328
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301116831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine