Provider Demographics
NPI:1740255306
Name:RAFEEA, IBTESAM M (MD)
Entity type:Individual
Prefix:DR
First Name:IBTESAM
Middle Name:M
Last Name:RAFEEA
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 1:5266 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3228
Mailing Address - Country:US
Mailing Address - Phone:313-914-3036
Mailing Address - Fax:
Practice Address - Street 1:5266 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3228
Practice Address - Country:US
Practice Address - Phone:313-914-3036
Practice Address - Fax:313-908-2247
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085086208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301085086OtherPHYSICIAN LICENSE
MIBR9193044OtherCONTROLLES SUBSTANCE REG.