Provider Demographics
NPI:1396951158
Name:GHABEN, KAMEL MOSTAFA (MD)
Entity type:Individual
Prefix:DR
First Name:KAMEL
Middle Name:MOSTAFA
Last Name:GHABEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KAMEL
Other - Middle Name:
Other - Last Name:MOSTAFA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:800-653-6568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301501030208000000X, 2080N0001X
TXN91012080N0001X
NJ25MA092547002080N0001X
PAMD4480922080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102812956Medicaid
TX280229001Medicaid
NJ3853501Medicaid