Provider Demographics
NPI:1649527243
Name:M DJAMALI MD PC
Entity type:Organization
Organization Name:M DJAMALI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHSEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DJAMALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-258-8449
Mailing Address - Street 1:PO BOX 81936
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48308-1936
Mailing Address - Country:US
Mailing Address - Phone:313-258-8449
Mailing Address - Fax:734-451-0603
Practice Address - Street 1:780 N LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-1529
Practice Address - Country:US
Practice Address - Phone:313-258-8449
Practice Address - Fax:734-451-0603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039115253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicare PIN