Provider Demographics
NPI:1992386445
Name:GHANDOUR, MALEK I (MD)
Entity Type:Individual
Prefix:DR
First Name:MALEK
Middle Name:
Last Name:GHANDOUR
Suffix:I
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 1:4201 SAINT ANTOINE ST STE 4E4F
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-4380
Mailing Address - Fax:313-993-0692
Practice Address - Street 1:4201 SAINT ANTOINE ST STE 4E4F
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4380
Practice Address - Fax:313-993-0692
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program