Provider Demographics
NPI:1942262217
Name:DAGHISTANI, LINA (MD)
Entity Type:Individual
Prefix:
First Name:LINA
Middle Name:
Last Name:DAGHISTANI
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 1:3250 E MIDLAND RD
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-2835
Mailing Address - Country:US
Mailing Address - Phone:989-667-6330
Mailing Address - Fax:989-667-6222
Practice Address - Street 1:3250 E MIDLAND RD
Practice Address - Street 2:SUITE A-2
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2835
Practice Address - Country:US
Practice Address - Phone:989-667-6330
Practice Address - Fax:989-667-6222
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051298208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF51318Medicare UPIN