Healthcare Provider Details

I. General information

NPI: 1285883371
Provider Name (Legal Business Name): ELMOATAZ IBRAHIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15945 19 MILE RD
CLINTON TOWNSHIP MI
48038-1147
US

IV. Provider business mailing address

43781 STONEY LN
STERLING HEIGHTS MI
48313-2259
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-0610
  • Fax: 586-263-0834
Mailing address:
  • Phone: 586-263-0610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301094678
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57-014393
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301094678
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: