Provider Demographics
NPI:1952373078
Name:ABOU-CHAKRA, IMAN S (MD)
Entity Type:Individual
Prefix:
First Name:IMAN
Middle Name:S
Last Name:ABOU-CHAKRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-1431
Mailing Address - Fax:517-841-1432
Practice Address - Street 1:1201 E MICHIGAN AVE
Practice Address - Street 2:STE 300
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1852
Practice Address - Country:US
Practice Address - Phone:517-841-1431
Practice Address - Fax:517-841-1432
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH350835902081P2900X
MI4301082675208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000363133OtherANTHEM INS
OH2478591Medicaid
OH7138550OtherAETNA INS
OH270046615-001OtherMEDICAL MUTUAL OF OHIO
OHP00191177OtherRAILROAD MEDICARE
OH11195950OtherCAQH
OHP00191177OtherRAILROAD MEDICARE
OH11195950OtherCAQH