Provider Demographics
NPI:1134394661
Name:FANOUS, MEDHAT YOUSSEF ZAKHER (MD)
Entity type:Individual
Prefix:DR
First Name:MEDHAT
Middle Name:YOUSSEF ZAKHER
Last Name:FANOUS
Suffix:
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 1:1400 W ICE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49935-9526
Mailing Address - Country:US
Mailing Address - Phone:906-265-6121
Mailing Address - Fax:
Practice Address - Street 1:1500 W ICE LAKE RD
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:MI
Practice Address - Zip Code:49935-8509
Practice Address - Country:US
Practice Address - Phone:906-265-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091790208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134394661Medicaid
MI1134394661Medicaid